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COPYRIGHT DEPOSET. 



Clinical Therapeutics 

A Handbook on the Special Treatment 
of Internal Disease 



BY 

ALFRED C. CROFTAN 

Author of "Clinical Urinology." 

Third Edition, Revised 



" Nihil temere affirmandum nihil contemnendum." 

(Hippocrates.) 
" Medicine is an Art that sometimes cures, often 
relieves and always comforts." 

(F. Berard.) 



CHICAGO 
(ftietrcfattii Press 

1910 






V 



Copyright 1910 

BY THE 

CLEVELAND PRESS 

CHICAGO 



<g CI. A 2-565 2 



"The observation which does not teach the art of healing is not that of 
a physician; it is that of a naturalist." (Broussais.) 



"La therapeutique est la seule raison d'etre de la medicine qui, sans 
son secours, ne serait guere qu'une meditation sur la mort." (Roger.) 



"Die Zeiten des Nihilismus in der Klinik und des Pessimismus in der 
Praxis sind uberwunden, sie liegen hinter uns." 

"Die innere Klinik steht heute unter dem Zeichen der Therapie." (v. 
Ley den. ) 



"II importe de rendre a la therapeutique sa dignite, de ne plus la 
confondre avec la matiere medical, et de remettre en honneur la science 
des indications. ' ' (Bouchard. ) 



"The doctrinaire in medicine, as in politics or other matters, is com- 
monly a dangerous person." (Duckworth.) 



DEDICATED TO MY WIFE 

ELIZABETH HUBBARD CROFTAN. 



PREFACE TO THIRD EDITION. 

There has been little real advance in the therapeutics of internal dis- 
ease within the last two years. Our main hope must lie in the field of spe- 
cific remedies; here the use of Flexner's serum in epidemic cerebro-spinal 
meningitis has fully vindicated its claim to usefulness; all other endeavors 
in the direction of preparing' specific sera have so far led to no conclusive 
results. Consequently there is little that is fundamentally new to add to 
this Third Edition. Alfred C. Croftan. 



PREFACE TO SECOND EDITION 

Within the short period of a few months that has elapsed since the 
issuance of the first double edition no fundamental advances in clinical 
therapeutics have been made. A number of promising ideas have been ad- 
vanced by different clinicians, but it is altogether too early to pass judg- 
ment on their validity ; for the present, therefore, I have preferred to omit 
them from the new text. Numerous suggestions, however, and a few criti- 
cisms that have been offered by readers of the first edition have, whenever 
feasible, been duty considered and incorporated in the volume. To all 
those who have been so kind as to aid me in this way I wish to express my 

-sincere appreciation. 

Alfred C. Croftan. 



PREFACE 



This book deals alone with the treatment of the sick. Hence the 
homely ministrations at the bed-side (that mean so much to the patient), 
the feeding and the bathing, the technique of all mechanical and physical 
means of treatment, as well as the use of medicines, the choice of climate 
and resorts, and the indications for surgical intervention are all discussed. 

As a profession we have erred in the past in giving too much medicine ; 
we err nowadays possibly in giving too little. With the development of 
modern pharmacology and the decline of crude empiricism ; with the tend- 
ency to give a single drug to meet definite indications; with the revival of 
esthetic medication and the abandonment of nauseous polypharmacy, drugs 
are recovering their legitimate place in the therapeutic armamentarium 
even of the most skeptically inclined. In the meantime physical means of 
treatment, such as hydrotherapy, electrotherapy, massage, the great prin- 
ciples of rest and exercise, all based upon accurate scientific observation, 
have won the position they deserve. Modern dietetics, founded on the 
newly-discovered laws of nutrition and metabolism, has become an exact, 
almost mathematical, procedure. Psychotherapy has been allotted a definite 
field of usefulness. Organotherapy and, above all, serumtherapy promise 
much and encourage the hope that our small list of specific remedies will 
shortly be increased. 

No attempt has been made to enumerate all the means and remedies 
that have at different times been recommended for the treatment of various 
diseases, for these belong to the historical rather than th« immediately 
practical. 

It is well to recognize our limitations in the field of treatment; hence 
rather than fill pages with a futile confession of our inability to help, a 
discussion of those disorders that we at present are unable to influence by 
any treatment has been altogether omitted. For this reason no special 
Section on Diseases of the Nervous System has been arranged; for unfor- 
tunately the majority of the organic diseases of the nervous system, on 
account of the peculiar character of the lesions and the nature of the 
affected parts, are not amenable to internal treatment, and the functional 
disorders of the nervous system are, as a rule, successfully treated only in 



X PREFACE 

special institutions. The management of the latter class of cases is discussed 
in the text under various headings and can be found by consulting the 
index. 

Occasionally an independent classification and grouping of related 
clinical entities has been attempted, in which I have considered it neces- 
sary from the therapeutic standpoint to depart from orthodox anatomic 
and etiologic classifications. Wherever it was considered essential to a 
better understanding of therapeutic indications, I have prefaced the state- 
ment of the treatment by general remarks relating to etiology and symp- 
tomatology. 

The author of a work on Therapeutics is of necessity forced to draw 
largely from personal experience, modified, to some extent, by the opinions 
prevailing among established authorities. This attitude naturally gives 
the discussion a subjective flavor, so to speak, which does not appear to 
me to be undesirable, and, which, above all, can hardly be avoided in a 
book of this character. 

In preparing certain chapters I have been so fortunate as to secure 
the co-operation of clinicians who enjoy exceptional opportunities for ob- 
serving the diseases they have written on. Thus Dr. Heman Spalding, as 
chief medical inspector of Chicago, has had a broad experience with the 
subject of Small Pox; Dr. "William H. Baum, as physician-in-charge of 
the contagious wards in the Cook County Hospital, has had unusual op- 
portunities for studying Scarlet Fever and Measles. Dr. A. Mayer and 
Dr. U. Maes, of New Orleans, have written on Yellow Fever. Dr. Wm. 
A. Pusey has contributed paragraphs on the X-ray treatment of Leukemia 
and Pseudo-leukemia; Dr. E. F. Wells has written the Section on Pneu- 
monia; Dr. F. S. Churchill on Mumps and Whooping Cough; Dr. F. 
Kreissl, the Sections on Syphilis and Cystitis and Urethritis and the para- 
graphs on intra-pelvic applications in the treatment of Pyelitis. To all these 
gentlemen I wish to express my sincere thanks for their earnest and valu- 
able assistance. 

In order to render this volume useful not only for consecutive read- 
ing, but also for rapid reference, marginal headings have been inserted 
throughout and particular care has been expended upon the preparation of 
a complete and exhaustive index. 

Alfred C. Croftan. 

Chicago, Nov., 1906. 



TABLE OF CONTENTS 

PREFACE 7— 8 

CHAPTER I. 

DISEASES OF THE CIRCULATORY APPARATUS 17— 70 

I. The Heart and its Membranes 17 — 53 

Valvular Diseases of the Heart 17 — 47 

In the Stage of Compensation 17 — 26 

In the Stage of Decompensation 26 — 34 

Stasis due to Valvular Disease 34 — 42 

Passive Hyperemia of the Brain 34 — 38 

Passive Hyperemia of the Lungs 38 

Passive Hyperemia of the Liver 38 — 40 

Passive Hyperemia of the Stomach and 

Intestine 40 — 41 

Passive Hyperemia of the Kidneys 41 — 42 

Cardiac Dropsy and Edema 42 — 47 

Myocarditis and Fatty Degeneration of the Heart. . 47 — 49 

Acute Endocarditis 49 — 51 

Pericarditis 51 — 53 

II. The Arteries 53— 63 

Arteriosclerosis and Chronic Aortitis 53 — 56 

Aneurism of the Aorta 56 — 63 

III. Neuroses of the Heart 63 — 70 

Angina Pectoris 63 — 65 

Palpitation 65— 70 

Arrhythmia 70 

CHAPTER II. 

DISEASES OF THE BLOOD 71—100 

L The Anemias 71— 86 

Progressive Pernicious Anemia 71 — 76 

Simple Anemia 76 — 80 

Chlorosis 81— 86 

II. Leukemia 86— 89 

III. Pseudo-Leukemia 89 — 93 



1 TABLE OF CONTENTS 

The X-Ray Treatment of Pseudo-Leukemia and 

Leukemia (Dr. W. A. Pusey) 93— 94 

IV. The Hemorrhagic Diathesis . . 95 — 100 

Scurvy 95— 96 

Hemophilia 97— 98 

Purpura 98—100 



CHAPTER III. 

DISEASES OF THE DUCTLESS GLANDS 101—111 

I. Diseases of the Thyroid Gland 101 — 109 

Myxedema and Cretinism 101 — 104 

Exophthalmic Goitre 104—109 

Simple Goitre 109 

II. Addison's Disease 110 — 111 



CHAPTER IV. 

DISEASES OF METABOLISM 113—196 

Introduction — The Laws of Nutrition 113 — 118 

I. Diabetes Mellitus 118 — 147 

Dietetics of the light form of Diabetes 125 — 128 

Dietetics of Diabetes of medium severity 128 — 130 

Dietetics of the severe type of Diabetes 131 — 139 

Medicamentous Treatment 132 — 138 

Exercise in Diabetes 139 

Treatment' of Complications and Sequelae of 

Diabetes .140—147 

II. Obesity . . 147—161 

Dietetic Treatment of Obesity 151—158 

The Science of Reduction Cures 151 — 154 

The Art of Reduction Cures 154—161 

III. Rheumatism 161 — 172 

Definition and Nomenclature 161 — 163 

Muscular Rheumatism, Myalgia 163 — 165 

Chronic Rheumatism and Rheumatoid Arthritis .... 166 — 172 

IV. Gout and the Uric Acid Diathesis 173 

Introduction — Uric Acid Physiology and Pathology. 173 — 186 

Retrocedent Gout . . . . .185—186 

The Acute Attack of Gout 186—188 

V. Rachitis 188—193 

VI. Osteomalacia 193—194 

VII. Diabetes Insipidus 194 — 196 



TABLE OF CONTENTS Xlll 

CHAPTER V. 

DISEASES OF THE URINARY APPARATUS 197—257 

I. Diseases op the Kidneys — Nephritis 197 — 242 

Introduction — Classification 197 — 198 

Acute Nephritis 198—204 

Chronic Nephritis and Bright 's Disease 204 — 222 

II. Pyonephrosis and Pyelitis 222 — 226 

Treatment of Pyelitis by Lavage of the Renal Pelvis 

(Dr. F. Kreissl) 224—226 

III. Nephrolithiasis 226—234 

Nephrolithiasis urica 227—233 

Nephrolithiasis oxalurica 233 

Nephrolithiasis phosphatica 233 — 234 

IV. Floating Kidney 234—236 

V. Uremia 236—242 

VI. Diseases of the Bladder 242 — 258 

Cystitis (Dr. F. Kreissl.) .242—248 

VII. Acute Urethritis (Dr. F. Kreissl) 248 — 257 

Gonorrheal Urethritis 248 — 254 

Prostatitis 253 

Epididymitis and Orchitis 253 — 254 

Infectious Urethritis of non-gonorrhoeal origin 255 — 256 

Tuberculous Urethritis 256 

Syphilitic Urethritis 256 — 257 

CHAPTER VI. 

DISEASES OF THE MOUTH AND UPPER AIR PASSAGES . 259— 278 

Introduction , 259 

I. Diseases op the Buccal Cavity 

Stomatitis 259—263 

Tonsillitis . . 263—265 

II. Diseases op tpie Nose and Throat 

Acute Rhinitis and Pharyngitis 265 — 269 

Coryza vasomotoria and Hay Fever 269 — 271 

Epistaxis 271—276 

Acute Laryngitis 276 — 278 

CHAPTER VII. 

DISEASES OF THE BRONCHI, LUNGS AND PLEURA 279—294 

I. Diseases of the Bronchi 279 — 294 

Acute Tracheo-Bronchitis 279—283 



XIV TABLE OF CONTENTS 

Chronic Bronchitis and Bronchiectasis 283 — 286 

Fibrinous Bronchitis 284 

Putrid Bronchitis 284 

Bronchial Asthma 286—290 

Capillary Bronchitis and Broncho-Pneumonia 290 — 294 

II. Diseases of the Lungs • 294 — 331 

Pulmonary Emphysema 294 — 299 

Pulmonary Edema 299—303 

Pulmonary Infarct, Abscess and Gangrene 303 — 306 

Hemoptysis 306 — 312 

Pulmonary Tuberculosis 312 — 331 

Fresh Air Treatment 312—316 

Climate and Altitude 316—319 

Dietetic Treatment 319—321 

Medicamentous Treatment 321 — 325 

Treatment of Special Symptoms 325 — 331 

III. Diseases of the Pleura 331 — 341 

Pleuritis 331—341 

Empyema 339—340 

Pneumothorax 340 — 341 

CHAPTER VIII. 

DISEASES OF THE DIGESTIVE APPARATUS 343—413 

I. The Stomach 343—413 

Acute Gastritis 343 — 354 

The Digestibility of Foods 347—354 

Chronic Gastritis . 354—366 

The Use of Hydrochloric Acid 359—362 

The Use of Digestive Ferments 364—366 

Gastric Ulcer 366—377 

Carcinoma of the Stomach 378 — 384 

Motor Insufficiency of the Stomach (Gastric Dila- 
tation, Gastric Ectasy, Gastric Atony) . . . .384 — 393 

Gastric Hypersecretion and Hyperchlorhydria 394 — 398 

Gastric Hyposecretion and Achylia Gastrica 398 — 401 

II. Gastric Neuroses 401 

Introduction — Definition and Classification .401 — 403 

Treatment of the Neurotic Individual 403 — 407 

"Weir Mitchell Cure 405—407 

Motor Neuroses 407 — 410 

Cardiospasm 407 — 408 

Pylorospasm 408 

Nervous Belching 408 — 409 



TABLE OF CONTENTS XV 

Nervous Vomiting 409 — 410 

Rumination and Regurgitation 410 

Pyloric Insufficiency 410 

Secretory Neuroses 410 — 411 

Sensory Neuroses 411 — 412 

Gastralgia 411—412 

Gastric Hyperesthesia 411 

Nervous Dyspepsia 412 — 413 

III. The Intestine 413—468 

Acute Intestinal Catarrh 413 — 418 

Chronic Intestinal Catarrh 418 — 423 

Intestinal Occlusion and Stenosis (Ileus) 423 — 437 

Intestinal Ulcer 437—440 

Membranous Enteritis and Mucous Colic 441 — 443 

Chronic Constipation 444 — 456 

Diarrhea 456—461 

Flatulency (Meteorism) 461—464 

Intestinal Parasites 464—468 

Tape Worm 464—466 

Pound Worm . , 466—467 

Thread Worm 467—468 

Uncinaria. Anehylostoma 467 — 468 

IV. The Peritoneum 468—484 

Acute Diffuse Peritonitis 468—471 

Acute Circumscribed Peritonitis, Perityphlitis and 

Appendicitis 471 — 481 

Chronic Peritonitis and Tuberculosis of the Peri- 
toneum 481—484 

CHAPTER IX. 

DISEAES OF THE LIVER AND BILE PASSAGES 485—505 

Catarrhal Jaundice 485 — 488 

Chronic Inflammations of the Liver (Atrophic, 
Hypertrophic Cirrhosis, Cardiac, Biliary 
Cirrhosis), Syphilitic Hepatitis, Hepatic 

Insufficiency 488 — 497 

Cholelithiasis 497—505 

Treatment of the Acute Attack 502 — 504 

Cholangitis and Cholecystitis 504 — 505 

CHAPTER X. 

INFECTIOUS DISEASES 507—603 

Introductory 507 — 511 

The Treatment of Fever 507—509 



TABLE OF CONTENTS 

The Fever Diet 509—511 

Typhoid Fever 531—539 

Diphtheria : 539—544 

Malaria 544—549 

Acute Articular Rheumatism 550 — 554 

Tetanus 554—557 

Dysentery 558 — 560 

Influenza 560 — 561 

Pneumonia (Dr. E. F. Wells) 511—530 

Nursing- and Sick Room Hygiene 517 — 519 

Pertussis (Dr. F. S. Churchill) 561—566 

Parotitis (Dr. F. S. Churchill) 566—567 

Scarlet Fever (Dr. W. L. Baum) 567—571 

Measles (Dr. W. L. Baum) 571—573 

Smallpox (Dr. Heman Spalding) 573—586 

Yellow Fever (Drs. A. J. Mayer and IT. Maes) . . . .586—593 
Syphilis (Dr. F. Kreissl) 594—603 



CHAPTER I. 

DISEASES OF THE CIRCULATORY 
APPARATUS. 

I. THE HEART AND ITS MEMBRANES. 

VALVULAR DISEASES OF THE HEART. 

Lesions about the valves of the heart cannot be repaired by Introductory 
any known means. As soon as one or more of the valves become 
narrowed or insufficient certain compensatory processes are set 
in motion that are intended to neutralize the effects of leakage 
or obstruction and in this way to restore normal circulatory con- 
ditions. The object of treatment in valvular lesions of the heart 
is, therefore, to aid the body in maintaining this balance of com- 
pensation, or in restoring it after it has begun to fail. The same 
indications must be met in so-called muscular or ' ' relative ' ' val- 
vular incompetence not due to valve lesions. 

It would merely complicate the understanding of the treat- 
ment of valvular disease if each lesion were discussed separately ; 
for the treatment of mitral and tricuspid incompetence and 
stenosis, on the one hand, and aortic incompetence and stenosis, 
on the other, is identical; pulmonary stenosis and common con- 
genital lesions of the heart are to be treated like mitral lesions ; 
pulmonary incompetence in its early stage like aortic incompe- 
tence, and later, when venous stasis becomes marked, like mitral 
lesions. 

The later manifestations of the different single and com- 
bined heart lesions are in most cardinal respects similar; i. e., 
in nearly all cases there is hypertrophy and dilatation of differ- 
ent portions of the heart, myocardial and arterial degeneration 
with changes in the blood pressure and ultimately venous stasis 
and cardiac dropsy in different organs. 

From a practical standpoint it is well to distinguish between 
the treatment of well compensated valvular lesions of the heart 
and those in which compensation is broken. 

TREATMENT OF COMPENSATED VALVULAR LESIONS OF THE HEART. 

The most important rule in the treatment of compensated Avoidance of 
heart lesions is to forego meddlesome interference. It is unfor- ^eart tonics 
tunate that, in well compensated valvular lesions, when a mur- 
mur is accidentally discovered recourse is so often had to the 
routine use of heart tonics. 



16 



COMPENSATED VALVULAR LESIONS OF THE HEART 



General 
indications 



Subjective 
symptoms in 
aortic insuffi- 
ciency requir- 
ing" special 
treatment 



Brain symp- 
toms and 
vagus symp- 
toms 



Opium 



Contra-in- 
dications to 
the use of 
opium 



Dose and ad- 
ministration 



The chief aim of treatment in compensated heart lesions is r 
(1) to maintain adequate nutrition of the heart muscle that is 
undergoing, or has undergone, compensatory hypertrophy; (2) 
to put the minimum strain upon the heart in order to enable it 
to maintain compensation; (3) to judiciously strengthen the 
heart muscle by various dietetic, climatic and hydro-therapeutic 
means, using drugs for this purpose very sparingly, and prefer- 
ably not at all. 

Fully compensated aortic insufficiency occasionally forms an 
exception to this rule, for, owing to the peculiar circulatory con- 
ditions that are created in this lesion, even when it is fully com- 
pensated by hypertrophy of the left ventricle, a variety of disa- 
greeable subjective symptoms are produced about the brain, the 
respiratory apparatus, the heart and the stomach that call for 
special symptomatic treatment. 

On account of the sudden regurgitation of the blood during 
each diastole, ischemia of the brain may be produced, with such 
symptoms as headache, dizziness, irritability, and a general 
psychic state resembling neurasthenia, with occasional fainting 
spells. At the same time dyspnea is not uncommon, produced 
presumably by irritation of blanches of the pulmonary plexus 
and of the vagus from direct pressure of the enlarged heart upon 
these nerves. 

In all these conditions the best remedy is opium; for in 
cerebral ischemia this drug acts in appropriate doses as a tonic 
to the higher nerve centers and produces plethora of the brain 
vessels which successfully counterbalances the anemia produced 
by the aortic insufficiency ; at the same time by acting as a nerve 
sedative it relieves the nervous dyspnea discussed above. 

There is one contra-indication to the use of opium or mor- 
phine in aortic insufficiency, and that is derangement of the ex- 
cretory powers of the kidneys. If the latter are diseased opium 
treatment should not be instituted, for otherwise a cumulative 
action due to deficient elimination of opium may be brought 
about. Idiosyncrasies to opium and morphine should, of course, 
also be included in the calculation; hence it is well, in these 
cases, to proceed with caution and to administer small doses 
in the beginning in order to study the effect of this drug 
upon the individual. It is best to begin with the hypodermic 
injection of doses of morphine hydrochlorate, not to exceed one- 
twelfth grain (0.005 gm.), gradually increasing the amount if 
no untoward symptoms appear. That it is best not to let the 
patients know what drug they are receiving need hardly be em- 
phasized as otherwise the morphine habit may be created. If 
after a few days it is found that morphine is tolerated and if 



COMPENSATED VALVULAR LESIONS OF THE HEART 19 

the symptoms are relieved by it, then the internal administra- 
tion either of morphine or of opium may be begun. Here, pow- 
dered opium in doses of from one-third to one and one-half grains 
(0.02^ to 0.1 gm.), or laudanum in doses of five to twenty drops, 
may be given. As a tolerance for the drug is gradually estab- 
lished larger doses will have to be given. 

If the use of opium or its alkaloids is contra-indicated, or Bromides and 
if the patient develops too great a tolerance for them, bromides quinine 
may be used to advantage for the dyspneic symptoms and 
quinine for the cerebral signs; the former preferably as sodium 
bromide in fifteen or thirty grain doses (1 to 2 gm.) in milk or 
soda water ; the latter as quinine hydrobromate in doses of five to 
fifteen grains (0.3 to 1 gm.), two or three times a day. 

Two other disagreeable subjective symptoms sometimes re- Epigastric 
quire special treatment in well compensated cases of aortic in- palpitation 
sufficiency, viz., epigastric pain occasionally assuming the charac- 
ter of gastralgic attacks, and palpitation. The former condition 
is presumably a neurosis of the celiac ganglia or of the abdom- 
inal sympathetic produced by the continuous shocks that these 
nervous elements undergo when the abdominal aorta pulsates 
violently. 

The best local treatment both for the epigastric pain and Cold to the 
the palpitation is the application of cold to the epigastric or and^e^i 111111 - 
precordial regions; an ice bag may be applied for an hour, then trium 
removed for an hour and reapplied for an hour, and this plan 
continued until the distress is relieved. Occasionally the con- 
tinuous application of cold by means of a "Leiter Coil" for sev- Leiter coil 
eral hours is more efficacious. This apparatus consists of a flat 
coil of thin rubber or metal tubes fastened to a piece of cloth or 
rubber that can be shaped to fit the outline of any part of the 
body. The cold water flows, from a pitcher that is elevated 
about three or four feet above the patient, through the Leiter 
apparatus to a pan placed at the foot of the bed. As the calibre 
of the tubes is very small the water flows slowly and the pitcher 
does not have to be filled more than once an hour or so. The 
flow is started by sucking on the lower tube. Rarely, heat ap- Heat 
plied locally by means of a hot water bag acts more beneficially 
than cold. 

Of drugs opium, quinine and bromides are again useful in opium 
these conditions, the bromides particularly in severe nervous Brom > des 
palpitation (see also page 68). Valerian in the form of quinine Valerian 
valerianate, dose one to three grains (0.5 to 0.15 gm.), is also 
often useful. In extreme cases of gastralgia cocaine may be 
used. A convenient way to administer the drug in this condi- Cocaine in 
tion is to prepare a five per cent, solution, to pour twenty drops S astral S ia 



20 



COMPENSATED VALVULAR LESIONS OF THE HEART 



Diet 



No large 
meals 



Avoidance of 

fermenting 

foods 



Extractives 



Albumen-fat 
diet 



of this into about one-third of a glass of water and to adminis- 
ter a teaspoonful of this mixture every fifteen minutes for four 
or five doses or until the pain is relieved. 

In the treatment of all compensated valvular lesions of the 
heart the diet is of extreme importance. It should be nutritious 
so that the heart muscle can sustain the excessive labor that it 
is forced to perform in order to maintain compensation, it should 
neither irritate the heart nor, by distending or inflating the 
stomach and bowels, mechanically interfere with the heart's 
action. 

The diet should, therefore, incorporate the full complement 
of calories requisite to maintain nutritive equilibrium (see the 
Chapter on Metabolic Disorders.) Large meals should, how- 
ever, never be allowed, for a full stomach pushes the diaphragm 
upwards, interferes with its respiratory excursions, and hence 
embarrasses the right heart. 

Aside from mechanically interfering with the heart's action 
large meals favor a determination of venous blood to the diges- 
tive viscera and hence impose much labor on the right heart, 
while at the same time setting certain nervous reflexes in mo- 
tion that cause palpitation and irregular cardiac action. There- 
fore a patient with a compensated heart lesion should be in- 
structed to eat small meals, at frequent intervals, rather than 
two or three large meals at long intervals. 

For similar reasons the diet should contain a minimum of 
those articles that cause gaseous distension of the stomach, as 
for instance, cabbage, potatoes, peas, beans, lentils, sauerkraut 
and aerated beverages. Nor should the diet contain any articles 
that can irritate the heart, for stimulation of the heart muscle 
when it is already working excessively is to be strenuously 
avoided; thus all meat extractives (see below), condiments and 
spices, tea and coffee should be forbidden. Alcoholic beverages 
should be taken very moderately and tobacco should, preferably, 
be absolutely forbidden. 

The diet should therefore consist largely of albuminous and 
fat foods and should contain relatively little of starchy foods. 
An albuminous diet increases the hemoglobin content of the 
blood so that the nutrition of the heart muscle is thereby aided. 
Some discretion should be exercised in advising the kind of 
albuminous food and its mode of preparation. Raw, rare, smoked 
and cured meats, as well as all internal organs like liver, sweet- 
breads, kidneys, etc., should be forbidden, or at least greatly re- 
stricted, because they are rich in extractives, and the latter 
(consisting largely of purin bases and their congeners), noto- 
riously irritate the heart and increase the blood pressure. For 



COMPENSATED VALVULAR LESIONS OF THE HEART 21 

the same reason bouillons and meat extracts should be tabooed, 
for they are practically a solution of these extractives. All 
other meat preparations, all vegetable albumens and milk, are 
very useful sources of readily digestible albumen. 

Fats, in the form of butter, cream, olive oil, a little bacon, Fats 
mayonnaise, etc., are valuable adjuvants to the diet, for they 
possess a high nutritive value (1 gm. of fat develops nine cal- 
ories) and at the same time soon produce a sense of satiety and 
hence prevent the patient from overloading the stomach. Fresh 
or stewed fruits and green vegetables fulfill a similar purpose 
and also act beneficially by counteracting constipation. 

The use of bread, potatoes, pastry, cereals, rice, sweets and Carbohydrates 
other carbohydrates should be reduced to the minimum com- 
patible with maintenance of the appetite and the enjoyment 
of food, for starchy and sweet foods are apt to produce flatu- 
lency and if taken abundantly cause engorgement of the liver 
and consequently impose added labor upon the rig} t heart, 
which, above all, should be spared in valvular lesions for the 
right ventricle is by structure less fitted to undergo compensa- 
tory muscular hypertrophy than the left ventricle. 

One of the most beneficial dietetic means of treating com- Reduction of 
pensated valvular lesions of the heart is to reduce the liquid iqm s 
intake. For in this way the heart and arteries aie relieved of 
much labor, the stomach is not so apt to become distended, the 
blood becomes more concentrated and hence acquires more hemo- 
globin to the unit, and the weight of the body is reduced. 

Various theories have been advanced to explain these phe- OertePs ex- 
nomena, but none of them as yet offers a convincing explana- P lanatlon 
tion. Practical experience demonstrates clearly, however, that 
drink restriction generally produces good results both in com- 
pensated and in decompensated valvular lesions of the heart. 
Oertel, who originated, or, better, revived the method of drink 
restriction in heart disease, presupposed the existence of an 
hydremic plethora, i. e., an increase of the volume of the blood, 
especially in cases of failing compensation, which could only be 
corrected by reducing the amount of liquid ingesta and at the 
same time favoring the elimination of water by the various 
emunctories of the body. Exact determinations of the specific 
gravity and the freezing point of the blood have not borne out Mechanical 
this postulate. So much is clear, however, that all of the water explanation 
that is introduced into the stomach must needs pass several 
times through the heart and arteries before it leaves the body 
by the lungs, the kidneys and the skin, or becomes deposited in 
the tissues; and it is self-evident that this labor can be reduced 
by giving less liquid and that consequently the heart is thereby 



22 



COMPENSATED VALVULAR LESIONS OF THE HEART 



Determination 
of water 
equilibrium 



Technique of 
drink restric- 
tion 



Fasting 



Reduction of 
common salt 



Rest and ex- 
ercise 



spared. For this reason drink restriction constitutes a very- 
valuable prophylactic measure, and also has a place, subordinate, 
it is true, to other more energetic means in the treatment of de- 
compensated heart lesions. 

It is frequently important to determine whether a disturb- 
ance of the water equilibrium has already occurred, and this 
can best be done by measuring, for several consecutive periods 
of twenty-four hours, the water intake and output. If it is 
found that the excretion of water is far below the intake and 
if, above all, the patient during the period of observation gains 
several pounds in weight, then one is justified in assuming that 
retention of water is taking place, that, in other words, the heart 
and arteries are beginning to fail in their task of pumping the 
water to the emunctories of the body. When this occurs the 
patients should be instructed to reduce their liquid intake to about 
one to one and one-half litres of water or other fluids in the twenty- 
four hours. This restriction is frequently borne with difficulty, 
but most patients soon become accustomed to it, especially if 
the importance of the measure is explained to them. That more 
water should be allowed in summer than in winter is clear, for 
the loss of water via the sweat glands must be compensated ; or if 
there is diarrhea or emesis the loss of water from the bowels or 
the stomach should also be replaced. 

In extreme cases in which compensation threatens to fail 
v>^. water intake should be still further reduced. Occasionally 
it is a good plan to impose a complete fast for twenty-four or 
forty-eight hours. It will be found that when solid foods are 
withdrawn the craving for liquids is simultaneously reduced; 
for a fasting individual, even when allowed to drink water 
without restraint, will rarely take more than one litre in twenty- 
four hours. This is, of course, a heroic plan to be employed 
only in emergencies, but it will often be found of inestimable 
value. That the diet should contain as little sodium chloride 
(common salt) as possible need hardly be emphasized in this 
connection; for the ingestion of sodium chloride requires the 
ingestion of water to hold it in proper molecular concentration 
in the blood and hence, as is well known, produces thirst. That 
the amount of water drinking must also be governed somewhat 
by the presence or absence of complicating diseases, e. g., cer- 
tain renal and metabolic disorders, fever, etc., need hardly be 
emphasized. 

In all valvular lesions of the heart the regulation of rest 
and exercise is of extreme importance. It is a well known fact 
that many cases of heart disease, with threatening decompensa- 
tion, recover completely when placed at rest without further 



COMPENSATED VALVULAR LESIONS OP THE HEART 23 

treatment. In cases of valvular trouble without compensatory 
disturbances, complete rest in bed is, of course, unnecessary, but 
certain simple rules should nevertheless be adhered to in order 
to avoid over-taxation of the heart. Thus such patients should m ga ls a 
avoid moving about for an hour or more after meals, especially 
if they cannot adopt the plan of eating small quantities at 
frequent intervals; for after a heavy meal nearly two-thirds of 
the total blood collects in the abdominal veins, and it is mani- 
festly a precarious procedure in valvular disease to force all 
this blood through the right heart towards the periphery, an 
event that will invariably occur if muscular exercise is indulged 
in during the period of digestion. Exercise after a full meal 
generally produces a rise in arterial pressure and venous con- 
gestion in the lesser circulation, and this is to be avoided. 

The occurrence of dypsnea and of precordial distress after Terrain cure 
exercise is always a danger signal and the patients should be 
carefully instructed never to exert themselves to this point. In 
cases of compensated valvular lesions, and this applies also to 
cases in which the balance of compensation is not quite estab- Schott treat- 
iished, the so-called Terrain cure, i. e., graduated exercises on 
measured inclined paths, and the Schott exercise treatment* 
are frequently useful. They can best be carried out in certain 
resorts, chiefly Nanheim, where all arrangements for these treat- 
ments as well as skilled attendants can be found. 

Swedish massage, a plan of treatment that can be pursued Swedish mas- 
at home, is of great value in the treatment of compensated heart sa§>e 
lesions. It consists in a series of resistance exercises that must 
be regulated according to each individual case and should be 
carried out by an expert masseur. Some cases, owing to indi- 
vidual peculiarities that we do not understand, cannot bear these 
resistance exercises ; it is well, therefore, to avoid all routine and f a en e eral mas ~ 
to carefully study the reaction of the individual patient before 
advising the continued use of exercise treatment. All passive 
exercise treatment acts beneficially by facilitating the Aoav of 
venous blood from the periphery to the right heart, by reducing tJeThSpt** 
the peripheral blood pressure, increasing respiration, and by 
all these effects aiding the right heart 

*The Schott treatment is a combination of passive and active and 
resisting exercises of the trunk and extremities. The cardinal rules 
laid down by Schott for carrying out his treatment are the following: 
"1. The exercise should be performed slowly, steadily and without exer- 
tion. 2. The same movements should never be performed twice in suc- 
cession. 3. Each movement should exercise a different group of mus- 
cles. 4. The patient should rest after each exercise. 5. The pulse and 
breathing should be constantly controlled by the physician." The exer- 
cises should be performed for about half an hour in the morning and 
for twenty minutes in the afternoon, including pauses. If symptoms 
of stasis or stenocardiac attacks appear, the exercises must be stopped. 



24 



COMPENSATED VALVULAR LESIONS OF THE HEART 



Out door life 



Climate 



Altitude 



Hot and cold 
climates 



General massage is always useful for it, too, facilitates the 
back flow of the peripheral blood towards the right heart and, 
unless carried out too vigorously, reduces the arterial blood 
pressure and thus spares the heart. Massage of the heart itself 
has also been recommended but, unless carried out by an expert, 
this practice is altogether useless and may become dangerous. 

All exercise treatment should be carried out for a long time 
if any real benefits are to accrue. The patients with compen- 
sated heart lesions should endeavor to live as much as possible 
out of doors; for the breathing of abundant oxygen, by pro- 
moting full aeration of the blood, will exercise a beneficent 
effect upon the nutrition of the heart muscle. 

Here the selection of a suitable climate must be arranged. 
Four elements must be consider ed in selecting a resort for a 
case of valvular disease, viz., altitude, the mean temperature, 
the temperature variations, and the humidity. 

The decrease of the barometric pressure at an altitude fav- 
ors elimination of water and gases from the surfaces of the body 
and from the lungs, and stimulates an increase of the number 
of red blood corpuscles and of the total hemoglobin, hence in- 
creases respirations, exaggerates metabolism and improves the 
nutrition of the heart while, at the same time, increasing its 
labor. By sending patients to moderate altitudes this effect 
can be utilized to advantage as a mild stimulant and hence an 
exercise for the heart; but too great altitudes must be avoided 
for fear of overworking the heart and breaking the balance of 
compensation. Patients with heart disease, therefore, should 
be warned against altitudes over three thousand feet, and if no 
decompensation whatever is present, should be advised to live 
at an altitude between fifteen hundred and two thousand feet 
above sea level. If compensation threatens to fail, the patient 
should at once be removed from the altitude back to sea level. 

Extreme degrees of heat and cold should always be avoided 
in heart disease. Heat is always bad, for it exercises a depress- 
ing effect upon the whole organism, including the heart. Ex- 
treme cold, on the other hand, both by producing contraction 
of the peripheral arteries and by direct nervous influence upon 
the heart, raises the blood pressure and stimulates the heart to 
greatly increased activity that may fatigue the organ if its 
valves are diseased. Inasmuch, however, as it is easier by proper 
clothing to protect the body from the effect of cold than from 
the effect of heat, a cold climate, other things being equal, is 
less dangerous for a case of valvular disease of the heart than 
a hot one. Best of all, of course, is a temperate climate with 



COMPENSATED VALVULAR LESIONS OF THE HEART 25 

slight temperature variations and no extreme degrees of heat 
or cold. 

The humidity must, finally, also be considered in selecting a Humidity 
resort for a heart case. A dry, warm climate is always to be 
preferred to a moist, warm climate; for, when the air is dry, 
insensible perspiration enables the organism better to counteract 
the depressing effects of great heat than if the atmosphere is 
moist; and a dry, cold climate is more beneficial than a moist, 
cold climate, because in the former there is less radiation of heat 
than in a moist atmosphere so that the body can maintain its 
temperature with less tax upon the general metabolism and 
hence upon the cardio-vascular apparatus. 

There is a popular prejudice against bathing in heart dis- Bathing 
ease. Since the principles of hydriatic treatment have been 
made the subject of accurate scientific research, the exact in- 
dications and contra-indications for warm and cold bathing in 
heart disease are better understood. Very hot baths (100° F. Hot baths 
and above), owing to their depressing effect, are always to be 
avoided, for immersion of the body in hot water, by producing 
first a sudden short contraction followed promptly by a relaxa- 
tion of the cutaneous vessels, and later a lasting contraction, 
always taxes the vaso-motor center and the heart. In individ- 
uals with well compensated heart lesions, who are of the neuras- 
thenic type, this practice is particularly dangerous because in 
such subjects the vaso-motor centers are already in a state of 
unstable equilibrium; and in sufferers from arterio-sclerosis the 
fragility of the arterial walls renders hot bathing most pre- 
carious. Cold bathing should also be forbidden in any case of 
heart disease, for the application of cold to the surface of the Cold bathm S 
body always produces a severe initial shock with a reflex increase 
of the heart 's action and contraction of the peripheral arterioles, 
in other words, high arterial tension, and this means a strain 
and possibly an over-taxation of the heart. Sea bathing should g , ,,. ^ 
therefore, always be forbidden. 

Lukewarm bathing, viz., immersion of the body for ten Lukewarm 
or fifteen minutes at a time in water of 90° to 95° F., i. e., "baths 
slightly below the temperature of the body, is a very useful 
means of treatment. The water may be medicated by the addi- 
tion of four to five pounds of salt to a bath tub full of water. Salt baths 
In Nauheim, Kissingen, Marienbad, Franzensbad and other wat- 
ering places baths with carbonated water are given. They can 
be prepared at home as follows : Half a pound of sodium bicar- baths 
bonate is dissolved in a bath tub full of water (of about 90° 
F.) and about three-quarters of a pound of commercial hydro- 
chloric acid are slowly added, care being taken that there is 



26 



FAILING OK BROKEN COMPENSATION 



Rationale of 
bath tempera- 
tures slightly 
below the 
body tempera- 
ture 



Medicines in 
compensated 
valvular le- 



always an excess of soda. The patient should at first not re- 
main in the tub for longer than five minutes, nor should he be 
given such a bath in the beginning oftener than once every other 
day. Later the bath may be administered daily and for fifteen 
to twenty minutes at a time. The temperature of the water 
should not be allowed to drop below 80° F. After the bath the 
patient should be dried with warm cloths and put to bed for 
half an hour or an hour, with a hot water bottle to his feet. 
The patient should never become dyspneic while in the watery 
as soon as breathing becomes oppressed the bath should be 
stopped. 

The good effects derived from bathing in lukewarm water 
can be explained in this way: The temperature of the water, 
being slightly below the body temperature, exercises a very 
mild stimulation, through the peripheral and vaso-motor nervous 
system, upon the action of the heart, slowing and at the same 
time strengthening its beat: the salt or the carbonic acid gas 
cause some relaxation of the peripheral capillaries and hence a 
decrease in the blood pressure. This means that the heart is 
being gently driven while its work is being reduced. Judiciously 
carried out, this treatment, therefore, constitutes an ideal ex- 
ercise for the heart when its energies are beginning to flag. 

The use of medicines in compensated heart lesions is to be 
eschewed. Only rarely should it become necessary to give any 
heart tonic or vaso-dilator, or any of the other remedies that 
are to be presently discussed under the heading of decompen- 
sated heart lesions ; nor is any special benefit to be derived from 
the use of so-called general tonics. That drugs may occasionally 
be necessary to regulate the function of the stomach or the bowel, 
or to correct an underlying anemia with relative incompetence 
of the heart valves is self-evident. This medicinal treatment will 
be discussed in other chapters. 

Drugs useful in the treatment of certain subjective symp- 
toms of compensated aortic insufficiency have been discussed 
above. 



THE TREATMENT OF VALVULAR DISEASES OF THE HEART WITH FAIL- 
ING OR BROKEN COMPENSATION. 



Rest 



Position in 
bed 



The most important element in the treatment of failing com- 
pensation is absolute rest in bed. In cases of cerebral anemia, 
i. e., chiefly in aortic insufficiency, the horizontal position may 
be the most agreeable to the patients, but, as a rule, they will 
be more comfortable when semi-recumbent or sitting up daring 



FAILING OR BROKEN COMPENSATION 27 

a part of the day, even if there is some dyspnea ; for the blood 
pressure is always lower when the patient is erect or semi-erect 
than when in a horizontal position. It is generally difficult to 
persuade patients in early stages of decompensation to go to bed. 
If the matter is fully explained to them, however, they will 
usually comply with this order. As Brunton puts it, the patient 
should be told, "If you have sprained your ankle, you know 
perfectly well that every movement that you make is likely to 
keep up the mischief. What you must do is to go to bed and 
keep the ankle perfectly quiet. You must give the heart rest 
just as you give rest to the ankle. If you go on walking with 
the sprained ankle, it will become worse and worse, and finally 
you will be unable to do anything with it. If you go on exer- 
cising with a strained heart, then you will continue to get worse, 
and in the end you must either give it rest or die." Rest in 
bed to be efficacious should be continued for several weeks; the 
results obtained are frequently brilliant, and very often one 
will be able to get along very well without the use of any heart 
tonics or other medication. 

The diet should be essentially the same as in compensated Diet 
lesions of the heart, especially if the patient is put to bed be- 
fore the appearance of dropsies or passive congestion in differ- 
ent organs. If such complications of broken compensation have 
already made their appearance then the patient should be put, 
for a time at least, upon a diet consisting largely of milk; for Milk diet 
milk possesses a distinct diuretic action and constitutes an ideal 
food. It should be given at frequent intervals, in small quan- 
tities, preferably in the form of a milk-cream mixture, con- 
sisting of a tumbler full (i. e., about nine ounces) of a mixture 
of two-thirds milk and one-third cream to which are added two 
teaspoonfuls of lime water. It is rarely advantageous to put 
these cases upon an exclusive milk diet for the flooding of the 
circulatory apparatus with water is decidedly harmful. (See also 
page 210) . A little fresh fruit, an egg, or a little meat and some 
crackers may usually be added with impunity. 

The application of cold continuously or intermittently to cold to the 
the precordial region is a very valuable adjuvant to treatment Precordial re- 
and should be employed as described under compensated heart 
lesions (see page 19). If rest and a simple diet and local cold 
do not restore compensation in mild cases within a week or ten 
days, or if the case comes under observation at a time when Indications 
decompensation is far advanced, so that edema and congestion heart tonics 
of the lungs, the liver, the kidneys and other organs are pres- 
ent, then it becomes necessary to use heart tonics. 

The heart normally possesses a certain amount of reserve 



28 



FAILING OR BROKEN COMPENSATION 



Digitalis 



Dose of digi- 
talis 



Cumulative 
action 



Tolerance and 
susceptibility- 



Intoxication 
with digitalis 



force which it utilizes as soon as an excessive strain is thrown 
upon it. It responds, as is well known, to any sudden over- 
taxation by dilatation, a prolongation of the diastole and an 
increased force of the systole. In valvular diseases this reserve 
force is called upon continuously to establish compensation, and 
in order to meet this added requirement hypertrophy, especially 
of the left ventricle, occurs. An ideal heart tonic, therefore, 
should aid the heart in prolonging its diastole and in enforcing 
its systole to the maximum. 

The chief representative of this group of heart tonics is 
digitalis, for in appropriate doses it possesses precisely this 
power. Its chief effect is exerted upon the ventricles, stimu- 
lating them to increased contraction so long as the heart muscle 
is not in an advanced stage of degeneration. Digitalis also 
raises the peripheral blood pressure, partly from its action 
upon the heart muscle and the nerves of the heart, partly from 
its effect upon the vaso-motor centers, which it stimulates to 
cause contraction of the vessel walls; at the same time, it slows 
the action of the heart. Under the influence of digitalis the 
nutrition of the heart generally improves; this is due to the 
increased amount of blood supplied to the heart muscle when 
the ventricle contracts more energetically. 

The dose of digitalis is very important, for large amounts of 
the drug frequently produce an effect that is exactly opposite 
to that exercised by small doses, viz., they reduce the force of 
the systolic contractions and in lethal doses cause arrest of the 
heart in diastole. Its action is tardy, as it is slowly absorbed, 
so that a day or two may elapse before the effect of the drug 
upon the heart and the pulse becomes apparent. If the dose 
is increased too rapidly in the beginning (because its effect may 
not have appeared at once) intoxication from cumulative action 
may occur; and as the excretion of digitalis is as slow as its 
absorption, there is also always danger of cumulative action 
from disturbed excretion. Some individuals, moreover, seem 
to possess an idiosyncrasy against digitalis while others show a 
remarkable tolerance to its action. It is therefore always best 
to begin with small doses, and during the first days of its ad- 
ministration to carefully watch the heart, the pulse and the 
blood pressure for signs of digitalis poisoning. 

In susceptible subjects digitalis may, when first administered, 
produce disagreeable symptoms of a nervous character, as pal- 
pitation and insomnia, and sometimes symptoms of gastric or 
intestinal irritation, as nausea or diarrhea. These signs, however, 
can generally be ignored because they shortly disappear as soon 
as the organism accustoms itself to the drug. It is claimed thai 



FAILING OR BROKEN COMPENSATION 29 

some of the pure principles of digitalis possess only the cardiac 
action without the disagreeable local or general effects. All these "Pure Prin- 
principles, however, according to the best authorities are so Jj2ttJj lB °* 
uncertain in their action and vary so much in strength that 
their use can hardly be recommended excepting tentatively in 
those cases that display an absolute intolerance against digitalis, 
and these cases are very rare. (See also page 41.) If no signs 
of cumulative action or of particular susceptibility to the drug 
appear within the first two or three weeks of its employment, 
then there is no valid objection to a continued digitalis therapy, Continued use 
preferably using small doses for indefinite periods of time, even ° lgl a 1S 
years. This practice, if it can be carried out, is warmly recom- 
mended by many authorities and seems to be particularly useful 
in heart lesions combined with chronic arteritis and arterio- 
sclerosis (see also page 56). 

Occasionally a case of valvular disease comes under observa- chronic 
tion for the first time with a very slow and intermittent pulse, Digitalis 
great muscular weakness, gastric and cerebral symptoms; if 
on inquiry it is found that such a patient has been taking digi- 
talis for a long time it is always well to tentatively stop or 
greatly reduce the use of the drug in order to rule out the pos- Atropin as an 
siblity of chronic digitalis intoxication. If the heart is alarm- 
ingly slow one two-hundredth of a grain of atropine, hypoder- 
mically, should be given until the toxic digitalis effect wears 
off. 

Digitalis is contra-indicated in any case of failing compen- contra-indi- 
sation in which the heart muscle has begun to degenerate, espe- cations 
dally in advanced myocarditis and fatty heart, as here the 
heart cannot react to the drug; in fact, by increasing the blood 
pressure digitalis may seriously embarrass a heart with a weak 
musculature and cause disagreeable or dangerous complica- 
tions. For this reason the drug is less useful in aortic insuffi- 
ciency than in other, especially mitral, valvular diseases, be- 
cause aortic insufficiency rarely becomes decompensated until 
extensive degeneration of the left ventricle has occurred. This 
is due to the fact that the walls of the left ventricle are capable 
of undergoing enormous hypertrophy before they begin to fail, 
whereas, the right ventricle succumbs much sooner to over- 
strain ; as a result mitral lesions and lesions of the valves of the 
right heart produce failure of compensation much sooner than 
aortic lesions, and often at a time when the walls of the left 
ventricle are still intact, capable of hypertrophy and susceptible care in using 
to the action of digitalis. For this reason digitalis should be digitalis in 
given with the greatest care in diseases of the aortic valves and 
only after the absence of myocarditis has, so far as that is pos- 



30 



FAILING OR BROKEN COMPENSATION 



Digitalis in 
the diagnosis 
of myocarditis 



Digitalis and 
strophanthus 
in atheroma 



Digitalis with 
nitroglycerin 
and nitrites 



Preparations 
of digitalis 



sible, been established. In fact, digitalis may be used occa- 
sionally as a valuable diagnostic aid for detecting the presence 
of myocarditis. For degeneration of the heart muscle may be 
assumed if a digitalis effect, i. e., slowing of the heart beat, an 
increase of the pulse-tension and impulse, with a forcible apex 
beat and increased diuresis, do not appear within two or three 
days after the administration of the drug. In such cases, of 
course, it is very bad practice to continue with the use of digi- 
talis. 

Another contra-indication to the use of digitalis is extensive 
atheroma or fragility of the arterial walls, for here the in- 
creased pressure may lead to rupture of the vessel walls. 
Strophanthus should be the remedy of choice in these cases, be- 
cause it acts as a heart tonic without causing so great a rise 
of the blood pressure as digitalis. If it becomes necessary to 
give a heart tonic in such cases it is best, however, to use 
digitalis or strophanthus in combination with drugs like nitro- 
glycerin or nitrites that can lower the blood pressure ; remem- 
bering always that the effect of the nitrites becomes manifest 
much more rapidly than the effect of digitalis, so that the 
nitrites should be given several hours after the digitalis; and 
that the effect of nitroglycerin is very short so that it should be 
given in frequently repeated small doses, several hours after the 
digitalis has been taken. 

Of the many preparations of digitalis, the infusion and the 
tincture are, from a practical point of view, at least, the best. 
The infusion made from the leaves (that should preferably be 
cut into small pieces and not powdered) should always be fresh. 
It should be given in doses of from one to two fluid drachms 
(4 to 8 cc.) according to the requirements of the case. The 
alcoholic tincture of digitalis is of more uncertain composition 
and strength than the infusion; nevertheless, in the great ma- 
jority of cases, it will be found to be efficacious. The proper 
dose is from five to fifteen drops (0.3 to 1 cc.) three times a 
day. 

Occasionally it becomes necessary in patients who do not 
react properly to the infusion or tincture to give digitalis in 
the form of the powdered leaves in doses from one to four grains 
(0.05 to 0.2 gm.), either in a capsule with sugar of milk or in 
a pill. This preparation, however, often produces irritation of 
the stomach, which is especially the case among patients with 
venous stasis in the gastric veins due to heart disease, i. e., with 
congestive catarrh of the stomach. Here small quantities of 
the infusion, diluted with milk and administered ice cold, are 
frequently well borne. 



FAILING OR BROKEN COMPENSATION 31 

When the stomach will not tolerate digitalis the drug may ^.^^Ind 7 
be administered in the form of an enema and the infusion can hypodermically 
be used for this purpose. Such a clysma, preceded by a cleans- 
ing enema, may be given two or three times a day. Occasionally 
the administration of digitalis leaves in suppositories fulfills a 
useful purpose. The hypodermic administration of digitalis is 
usually very disagreeable, because digitalis exercises a local 
irritant action and the injection of the drug under the skin is 
usually painful. 

The chief glucosides of digitalis, viz., digitoxin, digi- «p ure prin- 
tophyllin, digitalin and digitalien are all extensively used and ciples" of digi- 
abundant literature has appeared on the subject. So far, how- 
ever, I have found it unnecessary, in the great majority of 
cases, to have recourse to these preparations, especially as their 
strength and efficacy are usually uncertain; and, old fashioned 
as it may appear, I give the infusion of digitalis, described above, 
and the powdered leaves, the preference over all other digitalis 
preparations. 

The effect of digitalis may occasionally be enforced by re- 
stricting the liquid intake or by sweating, or both. Alcohol, 
given half an hour before the digitalis, also makes the latter more 
effective. 

Brief mention may be made of certain other heart tonics 
that should occasionally be used, either if digitalis is not well 
borne by the patient or if a cumulative effect appears; the most 
useful among these in my experience are strophanthus, conval- 
laria, adonis vernalis and caffein. 

Strophanthus, like digitalis, strengthens the action of the Strophanthus 
heart muscle and slows the pulse, it also raises the arterial 
blood pressure, but not to the same degree as digitalis, nor does 
it possess the same diuretic strength. It may, therefore, be used 
to advantage in place of digitalis in cases of Valvular heart dis- 
ease with arteritis. The chief advantage it possesses over digi- 
talis is that it does not have a cumulative action, so that this 
drug can always be continued with safety for long periods of 
time. It seems that strophanthus is more irritating to the kid- 
neys, however, than digitalis, so that, in cases of cardiac dis- 
ease complicated with nephritis, especially in Bright 's disease, 
the drug should be administered with care. The best mode of 
administering strophanthus is in the form of the tincture, in 
doses of five to fifteen drops, three or four times a day. It may 
also be given in the form of strophanthin, hypodermically, ir 
doses of one one-hundred-and-fiftieth to one-fiftieth of a gra'n 
(0.0004 to 0.0012 gm.). 



32 



FAILING OR BROKEN COMPENSATION 



Adonis ver- 
nalis 



Convallaria Convallaria retards the heart's action, increases the arterial 

tension and possesses some diuretic power. It is not cumulative 
in its action and never irritates the stomach ; occasionally it even 
seems to stimulate the appetite. Convallaria is usually given in 
the form of the alcoholic tincture (five to ten drops) or the fresh 
watery extract (four to eight drops). 

Adonis vernalis increases the arterial pressure, strengthens 
and slows the heart beat. On account of its great blood pres- 
sure raising power it acts very well as a diuretic when the kid- 
neys are inactive and it is especially useful, therefore, in car- 
diac dropsy. In cases of interstitial nephritis, however, in which 
the blood pressure is already high, or in arterio-sclerosis com- 
plicated with heart lesions, the drug should be used with great 
care. It is best given in the form of the fresh infusion, one to 
four drachms (4 to 16 cc). 

Caffein Caffein strengthens the heart muscle, raises the peripheral 

blood pressure and increases diuresis, not, however, by its blood 
pressure raising power but by a specific action upon the renal 
epithelium. This drug, too, should never be given when the peri- 
pheral blood pressure is high, nor should it be given to very 
excitable individuals, nor to alcoholics on account of its well 
known action upon the higher cerebral centers. It not infre- 
quently produces insomnia, and occasionally hallucinations and 
delirium. It is particularly valuable as a substitute for digi- 
talis and the other heart tonics that exercise their effect directly 
upon the heart muscle, in cases in which the latter is beginning 
to degenerate, because caffein presumably manifests its effect not 
upon the heart muscle directly but upon the nervous apparatus 
governing the heart beat. 

The best preparation is caffein citrate, which may be given 
in doses of two to eight grains (0.1 to 0.5 gm.), or caffein may be 
administered hypodermically in combination with sodium sali- 
cylate or benzoate, the latter salts forming double compounds 
with caffein and preventing its decomposition with water. 

The drug should be given two or three times a day in the 
following solution: 



Salicylate of soda, 

Caffein, 

Water, 

M. 



30 gm. 
40 gm. 

60 cc. 



Dose for hypodermic use, ten drops ; or 



FAILING OR BROKEN COMPENSATION. 33 



Caffein, 


2.5 gm. 


Sodium benzoate, 


3.0 gm. 


Distilled water, 


10 cc. 


M. Sig. 1 cc. hypodermically. 





— (Tanret.) 

Of this solution each cubic centimeter contains four grains 
(0.25 gm.) of caffein. 

Theobromin, in capsule, in doses of eight grains (0.5 gm.l Theobromin 
Uiree times a day, or in solution with a little salicylate of soda; 
or dhifetin, in the same dose; may also be given in place of 
caffein or its citrate. 

Strychnia may also occasionally be used in small doses, one- strychnia 
hundredth to one-thirtieth grain (0.0006 to 0.002 gm.) to slow 
the heart and raise the blood pressure in failing compensation; 
it acts chiefly upon the vaso-motor center in the medulla and . 
the general nervous system. It slows the heart beat by its stimu- 
lating effect upon the inhibitory centre. It should never be 
used as a heart tonic when the arterial tension is high. 

In extreme cases of cardiac failure in which no time is given Analeptics 
to gradually strengthen the heart by the use of heart tonics, it 
becomes necessary to have recourse to analeptics, as an emer- 
gency measure. Chief among these are camphor, ether and am- Camphor 
monia. The clinical indications for the use of these remedies Ether 
are a weak apex beat, a feeble heart action, a great reduction in Ammonia 
the force of the radial pulse or its complete disappearance, cold- 
ness and lividity of the extremities and collapse. 

In such a condition, brandy or champagne and hot coffee may B , 
be administered, but camphor is the remedy par excellence, champagne 
either alone or as spirits of camphor twenty to thirty drops, or Coffee 
in combination with digitalis, thus: 

Camphor, 1 gr. (0.05 gm.). 

Powdered digitalis leaves, 2 gr. (0.1 gm.). 

For it possesses the power to excite the nervous system and 
to rapidly produce acceleration and increased strength of the 
heart's action. In an emergency camphor may be given hypo- 
dermically in 10 per cent, solution in ether or in sterile olive 
oil, twenty to thirty drops at a time. 

Ether, or "Hoffman's Anodyne" (Spir. iEtheris Comp.), a 
teaspoonful on sugar, or ether alone, hypodermically, are also the use of 

useful. Ether acts still more rapidly than camphor, and when- etner an <* cam- 
phor and am- 
ever it is desired to produce a very quick effect, ether should monia 



34 



STASIS DUE TO DECOMPENSATED VALVULAR LESIONS 



first be given and an injection of camphorated oil (see above) 
afterwards; or camphorated oil in ether, one part of ether to 
two of the oil, may be administered in the dose of two or three 
hypodermic syringes. Ammonia, in the form of the aro- 
matic spirits of ammonia, in the dose of fifteen to sixty minims 
(1 to 4 cc), frequently repeated, may also be employed. Supra- 
renalin, finally, hypodermically, in the dose of one-twentieth to 
one-tenth of a grain (0.006 to 0.003 gm.) is also a useful emer- 
gency medicine. 



Insomnia 

Irritability 

Psychoses 



Cheyne-Stokes 
breathing 



Stupor and 
Somnolence 



Treatment of 
insomnia 



Dangers of 
chloral and 



SYMPTOMATIC TREATMENT OF STASIS IN DIFFERENT ORGANS DUE TO 
DECOMPENSATED VALVULAR LESIONS. 

In advanced degrees of failing compensation venous stasis 
occurs in different organs of the body; and while the treat- 
ment of the symptoms produced by this passive congestion, 
notably in the brain, the lungs, the liver, the kidneys and the 
gastro-intestinal tract, is essentially synonymous with treatment 
directed towards improving the general heart action, as described 
in previous paragraphs, it occasionally becomes necessary in 
addition to relieve some of the most urgent symptoms that follow 
the congestion of these parts of the body. 

Passive Hyperemia of the Brain. Passive hyperemia of the 
brain is one of the most frequent and one of the most dis- 
tressing consequences of broken compensation. In mild degrees 
the chief symptoms are insomnia and general irritability, occa- 
sionally assuming the characteristics of monomanias or of other 
psychoses. As the medulla is, at the same time, usually in a 
state of congestion, respiration may become irregular and the 
Cheyne-Stokes type of breathing be produced. In late stages 
of failing compensation chronic venous congestion of the brain 
produces stupor and somnolence. 

If these symptoms do not readily yield to cardio-tonic medi- 
cation, then recourse must be had to remedies that control the 
nervous phenomena, especially the insomnia. In selecting rem- 
edies for this purpose among the numerous hypnotics and nar- 
cotics that we possess, the impaired condition of the heart must 
always be taken into consideration. For this reason chloral, 
which is deservedly one of the most popular hypnotics, cannot 
be used, for chloral exercises a depressing effect upon the car- 
diac muscle and the muscles of the blood vessels and also pro- 
duces paresis of the vaso-motor centres. It acts, in this respect, 
similarly to chloroform. Moreover, chloral is particularly 
contra-indicated in this form of insomnia because it produces 
congestion of the peripheral organs, including the brain, and 



STASIS DUE TO DECOMPENSATED VALVULAR LESIONS 6& 

this is precisely what we are attempting to counteract. The 
same objection applies to the use of opium and its alkaloids, for 
they too reduce the tone of the vaso-motor centres and the peri- 
pheral blood pressure, thus causing dilatation of the blood vessels 
and cerebral congestion. 

The most useful drugs in the treatment of this form of in- Bromides 
somnia are the bromides, for they quiet the sensibility of the 
whole nervous system, and in particular of the special senses, 
and hence enable the patient to go to sleep, simply because ex- 
ternal influences cannot stimulate the over-irritable brain. It 
has been claimed, moreover, that the bromides produce a dis- 
tinct anemia of the brain, and that this property can be used 
to counteract congestion. As a matter of fact, it has been shown 
by recent investigations that the anemia of the brain found in 
animals that were killed after having taken large doses of bro- 
mides, is no more intense than that found in animals killed when 
they were asleep ; so that the cerebral anemia observed after the 
administration of bromides must be considered due to the sleep, 
and the sleep not due to the cerebral anemia. 

The bromide of potassium should never be given in cerebral Bromide of 
congestion due to valvular heart lesions, because large doses of P otash 
potassium undoubtedly weaken the heart and reduce the blood 
pressure. The bromide of sodium produces less gastric irrita- Bromide of 
tion than the bromide of potassium; this drug should therefore soda 
be given, preferably in milk and in two divided doses of fifteen 
grains eachj the one about three hours before retiring and the 
other just before going to bed. It will be found that after a 
few days' treatment the patients will react more rapidly to 
smaller doses than in the beginning. 

Next in importance to the bromides are sulphonal and its 
congener, paraldehyde, and a group of drugs that are related 
to chloral but do not possess the depressing action of this remedy 
upon the heart, viz., chloralamid, chloralose, chloretone, and 
veronal. 

The continued use of sulphonal, however, is fraught with Sulphonal 
some danger and it should be employed with care in heart cases ; 
moreover, it does not seem to act as energetically in cases of 
failing compensation as otherwise. In giving sulphonal the 
urine should be carefully inspected. If it assumes a peculiar 
burgundy-red color the administration of the drug should im- 
mediately be stopped, for sulphonal, in persons who possess a 
peculiar idiosyncrasy to the drug, occasionally produces hemato- 
porhyrinuria.* It should be given in doses of from fifteen to 
thirty grains (1 to 2 gm.), in some hot beverage, about three or 

*See Tyson and Crof tan : Trans. Ass'n. Am. PJiys. 1901. 



36 



STASIS DUE TO DECOMPENSATED VALVULAR LESIONS 



Trional 



Paraldehyde 



Chloralamid 



Chloralose 



Chloretone 



Veronal 



Cannabis indica 



Bloodletting 



Leeches 



four hours before going to bed. As sulphonal is excreted very 
slowly it will be found that the dose can gradually be reduced. 

Trional acts more rapidly than sulphonal, and usually pro- 
duces sleep within an hour. It is given in the same dose as 
sulphonal, and is particularly efficacious if given in combination 
with codeine, one-fourth grain (0.015 gm.). 

Paraldehyde does not influence the heart in any way and 
produces a very rapid hypnotic effect, the patient usually going 
to sleep within ten or fifteen minutes. The drug should be 
given in doses of fifteen to sixty minims (1 to 4 cc), preferably 
in brandy and water. As the drug is largely excreted through 
the lungs, the patients for a day after the use of paraldehyde 
are apt to complain of a disagreeable odor of the breath, simi- 
lar to alcohol. 

Chloralamid is a compound of chloral and formamide and 
decomposes in the stomach with the liberation of formamide, a 
drug that counteracts the circulatory depression produced by 
chloral. Its hypnotic effect is very marked. Dose, fifteen to 
thirty grains (1 to 2 gm.). 

Chloralose, a glucoside compound of chloral, does not affect 
the heart at all and is an excellent hypnotic. It should be given 
in powder form in capsules containing two to five grains (0.12 
to 0.3 gm.) of the drug. This dose may be increased to two 
or three powders on succeeding days, if the desired effect is not 
produced by one powder. 

Chloretone does not irritate the stomach, especially in wat- 
ery solution, nor does it depress the circulation. It usually pro- 
duces a marked effect in small doses of five to ten grains (0.3 to 
0.65 gm.) and may be used as an alternative for some of the 
other remedies. 

Veronal, finally, is one of the most useful newer hypnotics 
in cerebral congestion. It acts exclusively upon the central 
nervous system, does not depress the heart or circulation, and 
leaves very slight after-effects. It may be given in doses of 
five to fifteen grains (0.3 to 1 gm.) in warm water or milk, 
or in capsule, about an hour and a half to two hours before 
sleep is to be produced. 

Of all the other commoner hypnotics that might be used can- 
nabis indica is mentioned merely to be condemned, for it ex- 
ercises a very deleterious effect upon the heart and circulation 
and should never be used in sufferers from valvular disease. 

In addition to all these hypnotic and narcotic remedies, 
blood-letting, either locally or by venesection, is an exceedingly 
useful measure for combating cerebral hyperemia. Blood may 
be withdrawn locally, either by the use of leeches or by scari- 



STASIS DUE TO DECOMPENSATED VALVULAR LESIONS 37 

fication and cupping. As the latter procedure cannot be applied 
in blood-letting about the skull, the technique will not be de- 
scribed in this place. Leeches should be applied in cerebral con- 
gestion to the mastoid process. 

Good leeches should move about freely m water and should 
contract when touched. To induce the leech to take hold a drop 
of sugar solution or of milk is placed upon the skin, or, better 
still, a small incision is made so that a drop of blood oozes out. 
The skin, of course, should be thoroughly cleansed before the 
leech is applied. As a rule, the leech is allowed to suck blood 
until it lets go spontaneously. If it is desired to remove the 
leech before he has sucked all the blood he can, a little salt may 
be put upon his tail. If, on the other hand, it is desired to pro- 
long the bleeding after the leech has let go, the wound may be 
treated with a warm sterile solution of salicylic acid. 

Venesection usually produces a much more rapid effect and Venesection 
is particularly useful in venous hyperemia of the brain due to 
valvular disease. By withdrawing enough blood from a vein 
the heart is at once relieved of a great deal of labor, and re- 
sumes, for the time at least, its normal action, especially if 
venesection is enforced by cardio-tonic medication. Venesec- 
tion is performed as follows : The arm is compressed above the 
elbow with a handkerchief or a bandage, so that one of the three 
large veins on the anterior surface of the fore-arm becomes 
prominent; the skin is carefully disinfected over the place of 
incision and the scalpel introduced with the cutting edge for- 
ward into the vein. The cut should be made diagonally across 
the vein for by doing so both the circular and longitudinal 
muscle fibres, of the blood vessel wall are severed, and closure 
of the incision is thereby facilitated and accelerated. About 
3 cc. of blood to each kilo of body weight should be with- 
drawn, not more. After the desired amount of blood has been 
allowed to escape the constricting binder is removed and the 
wound tied up with a small pressure bandage. If the patient 
should faint during venesection, bleeding should immediately 
be stopped and the patient placed in a recumbent position, with 
the head lowered. If the subject is very fat it may be necessary 
to dissect down to the vein, a little operation that can readily 
be performed under local anesthesia. Occasionally the median 
cutaneous nerve is severed during this operation, producing a 
little pain or tingling along the distribution of this nerve ; these 
symptoms usually disappear within a day or two. Particular 
care should, of course, be taken neither to wound the posterior 
wall of the vein nor to sever the artery, and it is always well first 
to determine the position of the artery and to select that vein 



38 



STASIS DUE TO DECOMPENSATED VALVULAR LESIONS 



Passive hy- 
peremia of the 

lunars 



Cardio-tonic 
medication 



Danger of 
opium 

Tartar emetic 
Ipecac 



Ammonium 
chloride 
Tolu 
Benzoin 



Syrup of 
squills 



Venesection 



for incision which is farthest removed from it. Puncture of a 
vein with a trocar may also be performed but this procedure is 
not quite so safe. 

Passive Hyperemia of the Lungs. Passive hyperemia of the 
lungs due to valvular disease is very common. As a rule the 
dyspnea, the bronchitis and the hemoptysis readily disappear if 
the heart is treated. Occasionally, however, the congestion of 
the bronchial muscosa becomes chronic and a bronchial catarrh 
is produced that may call for special attention. Here the same 
remedies are useful as in other forms of bronchitis, so that I 
refer for the special treatment of this complication to the Chap- 
ter on Diseases of the Respiratory Organs. In heart disease, 
however, certain of our most popular expectorants become dan- 
gerous on account of their effect upon the heart; thus tartar 
emetic and apomorphine should never be used in these cases. 
Opium, morphine and ipecac should also be given with very 
great care. The former, because they -produce congestion and 
thereby merely aggravate the pulmonary hyperemia; the lat- 
ter, because it may produce vomiting and in this way severely 
strain the cerebral vessels which are congested, and hence may 
possibly produce cerebral hemorrhage. If the catarrh of the 
bronchial mucosa is dry and the secretions are expelled with 
difficulty, ammonium chloride or some of the preparations of 
benzoin, as syrup of tolu or compound tincture of benzoin, 
thirty minims to two fluid drachms (2 to 8 cc.) may be given. 
Codeine or heroin in one-sixteenth to one-eighth grain doses 
(0.004 to 0.008 gm.), repeated, are very useful in this condition 
especially for allaying excessive irritation and reducing the 
cough. The syrup of squills is particularly valuable, for scilla 
being a member of the digitalis series, possesses a marked car- 
dio-tonic effect; and hence it not only increases the bronchial 
excretion, promotes better expectoration and relieves the cough, 
but also supports and stimulates the heart. It may be given 
conveniently in the form of the syrup of squills in the dose of 
thirty to forty minims (2 to 3 cc). 

In pulmonary and bronchial congestion venesection is again 
a sovereign remedy; in fact, occasionally, spontaneous bleeding 
from the lungs is Nature 's way of relieving the hyperemia. The 
treatment of this hemoptysis if it should become severe is chiefly 
cardio-tonic. Ergot, of all remedies, should never be given (see 
Hemoptysis). 

Passive Hyperemia of the Liver. In valvular diseases of the 
heart, with failing compensation, passive congestion of the liver 
is particularly liable to occur. First, because the hepatic veins 
are so near the heart, so that any interference with the entrance 



STASIS DUE TO DECOMPENSATED VALVULAR LESIONS 39 

of the blood into the right auricle readily becomes manifest 
in the liver veins; second, because the pressure within the liver 
veins is naturally very low. For this reason we often encounter 
cases of valvular disease with only slight disturbances of com- 
pensation in which the liver is the first and only organ afflicted 
with passive hyperemia. Some of these patients actually com- 
plain of no symptoms about the heart, and suffer merely from 
pain in the epigastrium, a feeling of heaviness or pressure in Epigastric pain. 
the hepatic region, and gastro-intestinal disorders, all resulting Gastro-intesti- 
from the impaired circulation in the liver and the enlargement 
of the organ. 

The treatment here, as in other conditions of passive hyper- 
emia due to valvular diseases is primarily cardio-tonic. In addi- 
tion, however, it may become necessary to institute certain spe- 
cial treatment in order to relieve the symptoms just described. 

Chief among these is counter-irritation over the liver, either Counter irrita- 
by means of vesication, leeching or cupping. The method of iiVer° Ver G 
applying leeches has already been described. Cupping is per- 
formed as follows : The skin is shaved and thoroughly cleansed. 
An ordinary cup or the special apparatus that is constructed for Cupping 
the purpose, is warmed and placed upon the skin. Owing to the 
vacuum created within the cup the cupped area becomes hyper- 
emic and this constitutes an efficient counter irritation. If it is 
desired to withdraw blood by cupping the surface of the skin 
should be scarified and the cup applied as above; in this way 
several ounces of blood can be withdrawn. 

The ice bag also occasionally affords relief, especially if it Ice bag; 
is applied intermittently, i. e., left on for one hour and removed 
for one hour. The ice bag, of course, should never be applied 
directly to the skin, but a few layers of gauze or a handkerchief 
must be placed between the skin and the ice bag. 

In other cases heat is more grateful. Mustard plasters and Heat 
poultices made of bread, linseed, cranberries or oatmeal can also 
be used to apply heat and at the same time to counter-irritate. 
Occasionally it is useful to add some narcotic to the poultice, poultices 
and this can best be done by dipping a small piece of linen into 
tincture of opium or belladonna and placing it into the material 
that forms the poultice. A very useful method of applying 
continuous heat, locally, is to use a thermophor, i. e., an ordi- Thermophore 
nary rubber bag filled with sodium acetate. By leaving this 
bag in boiling water for ten minutes the acetate is dissolved. 
The thermophor is then wrapped in a hot cloth and applied to 
the surface of the body. As the salt crystallizes out again, heat 
is liberated and, in this way, a temperature of from 40° to 50° 
C. (105° to 122° F.) can be maintained for several hours. 



40 



STASIS DUE TO DECOMPENSATED VALVULAR LESIONS 



Anal leeching 



Mineral 
■waters 



Diet in passive 
congestion of 
the liver 



Vegetable 
laxatives 



Another method is occasionally used in the treatment of 
hepatic congestion due to cardiac weakness, viz., the withdrawal 
of blood, preferably by leeches, from the anal region. This 
empirical method was first described by Sacharjin, and is use- 
ful as well in hyperemia of the brain and the spinal cord and 
in stasis in the portal circulation, as in hemorrhoidal condi- 
tions. The leeches may either be applied to the perineum or 
to the sacral region. If a leech should crawl into the rectum, 
a solution of common salt (2 to 5 per cent.) should be injected 
in order to kill the animal. 

In passive hyperemia of the liver the alkaline and saline 
mineral waters are very useful. Chief among them are the 
waters of Marienbad, Kissingen and Franzensbad. Bitter 
waters, especially Hunyadi-Janos, are also useful. Jf the kid- 
neys are affected, or if there is much anasarca, the taking of 
these waters is, however, contra-indicated. Cases of hepatic 
hyperemia are usually benefited by a "cure" in Kissingen or 
Marienbad and similar watering places, not only because they 
drink the waters, but also because they are forced to live a 
more sensible life and are placed upon a strict and rational 
regime. 

The diet should contain very little carbohydrate food, be- 
cause starches and sugars always produce a digestive conges- 
tion of the liver, an effect that is above all things to be avoided. 
For the details of the diet in hepatic insufficiency due to stasis, 
I refer to the Chapter on Diseases of the Liver. In cases of pas- 
sive hyperemia of the liver with renal symptoms, in which the 
saline and alkaline waters may have to be eschewed, certain vege- 
table laxatives are useful. Chief among them are rhubarb, 
aloes, podophyllum, cascara sagrada. Calomel also has its place 
in this affection. All these remedies are intended to act as 
laxatives, and their exact administration and dose will be found 
described in the Section on Diseases of the Intestine. 

Passive congestion of the stomach and intestine is a very 
common and a very disagreeable symptom of cardiac weakness. 
It may be due either directly to the interference with the 
venous back-flow from the gastro-intestinal mucosa, or to pas- 
sive hyperemia in the liver, with resulting stasis in the portal 
system. In many cases the picture presented is that of a gastro- 
intestinal catarrh (occasionally with hematemesis, see page 376), 
and the treatment of this condition differs in no respect from 
the ordinary treatment of snch a catarrh, with this exception, 
that combined with the usual dietetic and medicinal measures 
employed for its relief (see page 376), energetic cardio-tonic 
treatment should be simultaneously instituted. Here one dii- 



STASIS DUE TO DECOMPENSATED VALVULAR LESIONS 41 

flculty is encountered, viz., the danger of giving digitalis by 
mouth, on account of the irritating action that this remedy oc- 
casionally exercises upon the stomach. This objection, however, 
is more theoretically constructed than practically important; 
for only in rare cases do we find the irritability of the stomach 
so great that digitalis cannot be given by mouth. If the in- Method of _ 
fusion of digitalis is given in small quantities at a time, and if f^lis 
it is given ice cold, difficulties will rarely be encountered. If 
necessary, dgitalis can be given in the form of an enema or in 
a suppository, or, as a last resort, in the form of digitalin, one- 
sixtieth grain (1 mg.), hypodermically. 

Passive Hyperemia of the Kidneys. Passive hyperemia of 
the kidneys, finally, aside from cardio-tonic treatment, calls for 
a careful regulation of the diet. It is important to recognize 
the character of the renal difficulty, i. e., to decide whether or 
not there is present a real nephritis or merely stasis in the kid- 
ney. The presence of valvular lesions and evidence of embar- 
rassment of the venous circulation in other organs usually de- 
cides the question. The urine as a rule is concentrated, owing 
to a relative increase of urea, uric acid and urinary pigments; 
hence its specific gravity is high and it has a tendency to precip- 
itate an abundant urate sediment. Its color is usually very dark. 
There is rarely much albumin. Hyaline casts, in small numbers, 
are commonly present, also a few leucocytes and an occasional 
red blood corpuscle. Renal epithelia, granular or blood casts are 
generally absent.* 

In these cases a milk diet is useful. Too much milk should Milk diet 
not, however, be ordered, nor should large quantities of milk be 
given at a time. The milk diet, by leading to the formation of 
small quantities of irritating urinary end-bodies, spares the 
kidneys; it also acts to a certain extent as an intestinal anti- 
septic and hence prevents the formation in the bowel of putre- 
factive poisons that can irritate the heart and the kidneys; in 
addition, it possesses diuretic properties which act advantage- 
ously by stimulating the kidneys to an increased secretion of 
water. The only objection to an exclusive milk diet is the dan- 
ger of flooding the cardio-vascular apparatus with large quan- 
tities of water, and hence forcing the heart to perform much 
labor in pumping the water from the stomach to the emunctories 
of the body. Consequently the total amount of milk should 
rarely exceed one quart in the extreme; and a little meat, fats, 
cereals, fresh fruits and vegetables should be added to the diet 
in order to make up the nutritive deficit. 

*See Croftan: "Clinical Urinology;* 



42 



TREATMENT OF CARDIAC DROPSY 



Rest and 
massage 



Diaphoresis 



Pilocarpine 
contra-indi- 
cated 



Hot air and 
steam sweats 



TREATMENT OF CARDIAC DROPSY AND EDEMA. 

Mild dropsical swellings about the ankles can usually be 
promptly relieved by rest in bed, massage and a milk diet. As 
soon, however, as an accumulation of serum occurs in the serous 
cavities and the subcutaneous tissues, more active treatment must 
be instituted. The means at our disposal are stimulation of the 
action of the sweat glands and the kidneys, and catharsis. If 
these measures fail, surgical treatment of hydrops must be in- 
stituted, either by incision or puncture of the edematous ex- 
tremities and drainage, or by paracentesis of the dropsical ser- 
ous cavities. 

The stimulation of the sweat glands should be brought about 
preferably by physical means; for we know of only one remedy 
that really possesses the power of stimulating the sweat glands, 
viz., jaborandi and its alkaloid, pilocarpine; and unfortunately, 
this drug is distinctly contra-indicated in valvular diseases of 
the heart, for it depresses the heart decidedly, slows its action 
and appreciably reduces arterial tension. 

Inasmuch as hot bathing is always dangerous in heart dis- 
eases, for reasons that have been described (see page 25), re- 
course must be had to sweating by the use of hot air or steam. 
In order to do this at home the patient should be seated upon 
a chair, a woolen blanket fastened around his neck and draped 
in such a way about the person of the patient that it covers 
his whole body and the chair, i. e., forms a tent with the head 
protruding above. By placing a lamp underneath the chair a 
profuse sweat can soon be induced. Sweating in bed can be 
produced in the same way by arranging a frame work over the 
patient and covering this with blankets. At the side of the bed 
is placed a lamp and over the lamp a metal funnel to which is 
attached a rubber tube which conducts hot air underneath the 
blanket, care being exercised, of course, that the patient is not 
burned by the hot air. If it is desired to give the patient a 
steam bath, the steam from a kettle of hot water may be con- 
ducted under the blanket tent by means of the same funnel and 
tube arrangement. 

In all of these procedures the patient's head should be kept 
cool with cold baths or an ice bag. The hot air or steam sweating 
may be kept up for ten or fifteen minutes with safety. At 
the end of the sweating the patient should be wrapped in 
blankets and allowed to remain quiet for half an hour; at the 
end of this time the surface of the body may to advantage be 
bathed in lukewarm water, dried with a rough towel and rubbed 
with alcohol. 



TREATMENT OF CARDIAC DROPSY 43 

Among the diuretics that can be used for the relief of car- Heart Tonics 
diac dropsy the heart tonics (digitalis and its congeners), and Diuresis 
caffein, given either alone or combined, are the most useful rem- 
edies. To the caffein group belongs also the very popular med- 
icine, theobromin, and its compound with sodium salicylate, T^eobromin 
diuretin. All these caffein derivatives are renal diuretics and diuretin 
act by exciting the renal epithelia. Diuretin is best administered 
in powder form, in the dose of about ten to twenty grains (0.65 
to 1.3 gm.) three or four times a day. A useful prescription in 
cardiac dropsy consequently is : 

1* 

Powdered digitalis leaves, 0.1 gm. 

Diuretin, 1.0 gm. 

Sugar of milk, 0.3 gm. 

M. Sig. One such powder three or four times 
a day. 

As the hydrochloric acid of the, stomach seems to interfere 
with the absorption of diuretin this drug can advantageously 
be given in combination with sodium bicarbonate in a little 
milk. If diuretin fails to increase the flow of urine after two 
or three days, its use had better be discontinued and recourse 
had to some other remedy, notably calomel, in doses of two Calomel 
grains (0.1 gm.) repeated five to ten times a day, for several 
days in succession. This treatment may be repeated at inter- 
vals of a week or ten days. The diuretic effect of this drug is 
very striking. It is contra-indicated, however, if nephritis ex- 
ists, or if there is a severe anemia or much gastro-intestinal 
trouble. Salivation should be forestalled by the frequent use 
of a dilute solution of chlorate of potash or tannic acid as a 
mouth wash. (See Stomatitis.) If salivation appears, neverthe- 
less, calomel should be stopped at once. To counteract the 
irritative diarrhea five grains (0.3 gm.) of powdered opium may 
be given daily. Diuretic teas were formerly very popular but Diuretic teas 
they act presumably more through the hot water they contain 
than from any specific effect; as they must be taken in large 
quantities to be effective and as abundant water drinking, is 
contra-indicated, their use cannot be recommended. 

Sugar of milk may also be utilized as a diuretic in these cases. Sugar of milk 
Inasmuch as these patients are, as a rule, living on a diet con- 
sisting largely of milk this effect is produced anyhow; the 
addition of milk sugar in varying doses to the milk, however, 
frequently enforces the diuretic effect of the latter. Other 
sugars seem to possess a similar diuretic influence and the admin- 



44 



TREATMENT OF CARDIAC DROPSY 



Catharsis 



Saline cathar- 
tics 



Vegetable 
purgatives 



Croton oil 



Jalap 
Colocynth 
Podophyllum 
Elaterium 



istration of a solution of dextrose is occasionally very useful in 
increasing the flow of urine. 

Three classes of purgatives or hydragogue cathartics may be 
used to advantage in the treatment of renal dropsy, viz., saline 
cathartics, vegetable purgatives and mercurial purgatives. The 
chief saline cathartics are the sulphate of sodium (Glauber salt), 
the sulphate of magnesium (Epsom salt), the double tar- 
trate of sodium and potassium (Kochelle salt) and the citrate 
of potassium and magnesium. These salines, in contradistinc- 
tion to the vegetable and mercurial purgatives, do 
not irritate the intestinal wall, but act chiefly by in- 
creasing the molecular concentration (i. e., the osmostic 
pressure) within the intestine, and hence draw water 
from the serum into the bowel. In this way the blood be- 
comes more concentrated and in its turn draws water from the 
tissues; the saline cathartics also stimulate the peristaltic move- 
ment of the bowel through their bulk and in this way hasten 
the propulsion onward of the bowel contents. 

Sodium sulphate may be given in doses of thirty grains to 
an ounce (2 to 30 gm.). The sulphate of magnesium in the 
same quantities. Rochelle salts in doses of about one-fourth to 
one-half an ounce (8 to 16 gm.), and the citrate of potassium 
and magnesium in doses of fifteen to fifty grains (1 to 3 gm.). 
In addition there are a number of pleasant effervescent mixtures 
that may be given. The concentration of the solutions of these 
different saline cathartics is very important. They should not 
be more concentrated than ten per cent. The disagreeable taste, 
especially of the magnesium salts, can often be disguised by 
the addition of a little sugar or by giving the salts in milk. 

Among the vegetable purgatives the oils, castor oil and 
croton oil, have a very subordinate importance in the treat- 
ment of cardiac dropsies, because they do not produce a suffi- 
ciently active purgation unless given in doses so large as to 
produce serious irritation of the bowel wall. This applies 
particularly to croton oil. Inasmuch as the mucosa is gen- 
erally in a state of passive hyperemia in cases of valvular heart 
lesions that have progressed to the stage of dropsy, it is par- 
ticularly important not to give drugs that can irritate the bowel 
wall. The rhubarb, senna, aloes group are also little used in 
the treatment of cardiac dropsy; first, because they are all 
irritating and, second, because their action is relatively mild. 
The chief vegetable purgatives, therefore, that we must use 
are jalap and colocynth, podophyllum and elaterium. Of all 
these jalap is the most deservedly popular. Inasmuch as this 
drug occasionally produces nausea, vomiting and colic, it is 



TREATMENT OP CARDIAC DROPSY 45 

best to combine it with hyoscine or belladonna which counter- 
act this effect. The following official preparations of the U. 
S. P. are all useful: The Compound Cathartic Pill contain- 
ing colocynth, jalap, gamboge and calomel, given three at a 
time. The Vegetable Cathartic Pill containing colocynth, jalap, 
podophyllum, hyoscyamus and peppermint oil, given in similar 
doses as the above. The Compound Elaterin Powder contain- 
ing one part of elaterin in thirty-nine parts of milk sugar, and 
given in doses of one to four grains (0.06 to 0.25), and finally, 
the Pill of Podophyllin, Belladonna and Capsicum. The ap- 
pearance of blood or mucus in the stools, or other signs of gas- 
tric or intestinal irritation, contra-indicate the continuation of 
these remedies. 

If all these medicinal measures, with sweating by hot air or surgical 
steam, fail to relieve the dropsy, then recourse must be had treatment 
to what may be called the surgical treatment of cardiac hydrops. 

The surgical relief of hydrops or anasarca of the lower ex- 
tremities is more than a palliative measure, for, in many cases 
it will be found that the withdrawal of the fluid from the serous 
cavities or limbs, when combined with active cardio-tonic medi- 
cation, enables the heart to regain its tone and occasionally aids 
in the re-establishment of compensation. Unfortunately this 
happy result is only rarely seen. The simplest and the safest 
way of removing the dropsical swelling of the extremities is to 
make an incision. The patient should be ordered to sit up- incision 
right, or, at least, to keep the legs in a dependent position for 
several hours before the incision is made. The feet and legs 
are carefully cleansed with soap and water and the skin ren- 
dered aseptic with bichloride solution, alcohol and ether. The 
best place for the incision is the external margin of the foot, 
below the external malleolus, or the dorsum of the foot. The 
incision should be at least an inch or two long and should be 
carried completely through the skin. By placing a cloth, wrung 
out of very hot water, over the wound immediately after the 
incision is made, bleeding can be stopped. The wound is then 
covered with a piece of bichloride gauze, the feet wrapped in 
cotton and placed in a pan containing a litle dilute carbolic 
acid or bichloride solution. As soon as the bulk of the fluid is 
drained off the wound usually closes if a simple compression 
bandage is applied. 

A second method is the so-called Southey method, which con- southey 
sists in the insertion of a number of trocars deep into the sub- trocars 
cutaneous tissues of the leg. That this little operation should 
be performed with all aseptic precautions need hardly be em- 
phasized. To the protruding ends of the little trocars are at- 



46 



TREATMENT OF CARDIAC DROPSY 



Scarification 
and cupping 



Paracentesis 
of the Ab- 
domen 



tached rubber tubes upon which suction may be advantageously 
exercised in the beginning in order to start the flow of the 
serum through the tube; the region around the trocar may be 
painted with iodoform collodion or may be covered with anti- 
septic gauze. After the fluid is drained off and the canulae are 
withdrawn, the little holes can be closed with iodoform collodion 
or gauze. This method is not so safe as the incision method, nor 
does it produce the desired effect so rapidly. The method by 
incision, moreover, is not so painful as the insertion of trocars 
nor is the danger of infection of course so great from an open 
incised wound as from a semi-occluded punctured wound. 

The method finally of scarifying the tissues and cupping 
through a funnel that carries off the dropsical fluids and the 
blood is less practical and not as efficacious as incision or trocar 
drainage. In draining off large quantities of anasarca fluid 
cerebral anemia occasionally develops, so that the patient be- 
comes nauseated and dizzy and finally faints. When this oc- 
curs drainage should at once be interrupted, the patient's head 
lowered and ether or camphor administered hypodermically. 
. Paracentesis for the removal of ascitic fluids is always in- 
dicated when the accumulated fluid mechanically presses the 
diaphragm upward and in this way interferes with respiration 
' and the action of the heart, or if it compresses the stomach and 
bowels in such a way as to interfere with digestion. 

Occasionally paracentesis of the abdomen becomes necessary 
even without the appearance of compression symptoms in the 
thorax, without very considerable interference with the heart's 
action, and without the presence of much edema in other parts 
of the body. One is often surprised to find such an abdomen 
full of fluid in cases of valvular lesions that are not in an 
advanced degree of decompensation. Here the development 
of the ascites is due to portal stasis superinduced by the exist- 
ence of a "nutmeg" liver ("heart disease liver," cardiac cir- 
rhosis) and compression of branches of the portal vein within 
the atrophied organ. 

When performing paracentesis of the abdomen cardiac stim- 
ulants should always be held in readiness in order to counteract 
the possible occurrence of cerebral anemia that may follow the 
sudden engorgement of the abdominal veins with blood when 
the fluid is withdrawn and the intra-abdominal pressure is re- 
lieved. The tapping can be made with an ordinary trocar and 
can be performed with the patient either in a recumbent or in 
a sitting position. The skin should be thoroughly cleansed with 
soap and water, bichloride solution, ether and alcohol, and when 



MYOCARDITIS AND FATTY DEGENERATION OF THE HEART 47 

making the puncture care should be taken to avoid superficial 
blood vessels. If the abdominal wall is very edematous, the local 
anarsaca should first be removed by massage. It is usually a 
good plan to make a small incision before inserting the trocar, 
as the little operation is less painful if this is done. The en- 
trance of the trocar into the abdominal cavity is readily recog- 
nized by a certain "give," and there is no danger of wound- 
ing the bowel in simple ascites. As soon as the bulk of the 
fluid has been tapped off, the bowel is usually felt to lightly touch 
the trocar point and the flow stops. This is the signal 
for withdrawing the needle. The wound is covered with a 
small piece of iodoform gauze and the latter attached to the 
skin with iodoform collodion. No other dressing is as a rule 
needed. The patient should be instructed to lie for half an 
hour or so on the side opposite the puncture. This treatment 
is, as a rule, merely palliative and has to be repeated; the ex- 
ceptions to this rule are the cases of hepatic ascites mentioned 
above, in which the withdrawal of ascitic fluid frequently ex- 
ercises an effect that is very long lasting. 

Paracentesis of the pleural cavity is very rarely necessary Paracentesis 
in heart lesions. It is always an emergency measure and a last of the pleural 
means to be resorted to only when the accumulation of fluid in pericardium 1 
the pleura is very great and respiration and the action of the 
heart are interfered with to such extent that death would occur 
unless the fluid were withdrawn. The technique of this proced- 
ure will be found discussed under Pleuritis. Paracentesis o£ 
the pericardium is probably never indicated in cardiac dropsy; 
the technique is discussed in the part on Pericarditis with ef- 
fusion. 



MYOCARDITIS AND PATTY DEGENERATION OP THE 
HEART. 

Myocarditis is generally secondary to a variety of primary 

disorders of an infectious or toxic character. It is a common n 

, ,. . . i- P , . a ■ Causal and 

terminal condition m diseases of the coronary arteries and fail- prophylactic 

ing compensation. Cachectic conditions, chronic anemias, acute treatment 
articular rheumatism and malnutrition very often lead to myo- 
cardial changes; finally, it is a senile change. Causal and pro- 
phylactic treatment is throughout synonymous with the treat- 
ment of the underlying disorder. 

The recognition of myocarditis is never easy. The cardinal Recognition 
symptoms are a weak first sound at the apex, a weak second 
aortic sound, occasionally a fetal heart beat rhythm (embryo- 



<18 MYOCARDITIS AND FATTY DEGENERATION OF THE HEART 



Types 



Fatty infiltra- 
tion and fatty 
degeneration 



Diet in fat 
nee it 



Acute myocar- 
ditis 



Myocarditis in 
acute articular 
rheumatism 



cardia), low blood pressure, a slow, small, feeble, soft, com- 
pressible pulse. Moreover, a heart with myocarditis generally 
fails to react to digitalis, so that the diagnosis can occasionally 
be made if the heart does not become slower, the blood pressure 
higher and diuresis increased after the administration of an 
appropriate dose of digitalis. 

The degeneration of the myocardium generally assumes a fatty 
type. In treating established myocarditis it is important to dis- 
tinguish between fatty infiltration of the heart muscle, due to 
degeneration of the muscle fibres, and fatty infiltration due to 
the interposition of fat between intact muscle bundles. The 
latter condition is generally combined with fatty overgrowth 
about the heart and is in most cases a symptom of a general 
obesity. The symptoms of true degeneration of the heart muscle 
and of fatty heart (cor adiposum) are very similar, but the 
treatment is, as a rule, different. 

In the former instance the diet should be arranged in such 
a way as to reduce general obesity. The details are given in the 
Chapter on Disorders of Metabolism. Oertei's Terrain cure (see 
page 23) is the most valuable means, however, for treating pa- 
tients with cor adiposum. This exercise treatment stimulates oxi- 
dation, gradually exercises the heart muscle and hence helps re- 
store its tone by favoring the back-flow from the periphery to- 
wards the heart, while at the same time stimulating the heart to in- 
creased contractions. This treatment, of course, can only be carried 
out in resorts that are arranged for such purpose. In myocarditis 
consecutive to coronary or valvular disease with failing com- 
pensation it should, however, never be employed. 

In early stages of myocarditis the same principles should 
obtain as in the treatment of valvular disease of the heart with 
failing compensation, and of endocarditis. (For the details of 
this treatment I refer to the respective sections.) 

Acute myocarditis, when fully developed, should be treated 
by rest, physical and mental, a bland, non-irritating diet and 
counter-irritation over the precordium by means of cold, leeches, 
cupping or plasters. Digitalis and other cardiac tonics should 
always be used with great care in acute myocarditis, especially 
if the digitalis effect does not become apparent within two or 
three days after the commencement of its administration. In 
emergencies analeptics may have to be given to save life (cam- 
phor, ether, ammonia, (see page 32). 

In myocarditis developing in the course of acute articular 
rheumatism, salicylate of soda should be discontinued at once 
and quinine and alkalies administered instead, the former as 
quinine sulphate in doses of three to five grains (0.2 to 0.3 



ACUTE ENDOCARDITIS 49 

gm.) ; the latter preferably as sodium bicarbonate, in doses of 
fifteen to thirty grains (1 to 2 gm.). 

In chronic myocarditis due to fibroid degeneration and Chrome myo- 
atrophy of the heart muscle, restitution to normal conditions 
is impossible and treatment is altogether palliative. All violent 
exercise, mental over-strain or worry, and emotional shocks 
should be carefully avoided. Sexual intercourse should be abso- 
lutely forbidden. The general health should be built up by a 
nutritious diet appropriate to the state of the digestive organs. 
Tea, coffee, alcohol and tobacco should be interdicted. A course 
of arsenic often acts as an effective general tonic. Fowler's 
solution should be given, beginning with two or three drops a 
day and gradually increasing the dose until twenty or thirty 
drops a day are taken, and then slowly reducing the dose until 
two or three drops are again reached ; such a course may be re- 
peated two or three times. Constipation and flatulency should 
be counteracted and anemia treated by appropriate remedies 
(see index). Cardiac tonics should be given, if at all, under 
careful supervision, and the same general rules should be fol- 
lowed as in the treatment of valvular diseases during the stage 
of compensation. 



ACUTE ENDOCARDITIS. 

Acute endocarditis may appear as a primary affection, but 
it usually complicates a great variety of general diseases, chief 
among them acute articular rheumatism, scarlet fever, pneu- 
monia, chorea, septicemia, erysipelas and gonorrhea. Syphilis 
and all cachectic states also occasionally determine inflammation 
of the endocardium. 

Prophylactic treatment is identical with the treatment of Prophylaxis 
the underlying disorders. Absolute rest in bed, and cold to 
the precordium, are the only measures that can be adopted to 
reduce the liability of the endocardium to involvement in the 
disease process. Rest, above all, should be enforced in acute 
articular rheumatism, gonorrheal arthritis and chorea, even if 
the general manifestations are slight, for, in the mildest case 
the liability of the endocardium to involvement should be re- 
membered and absolute rest insisted upon. In many cases of 
tonsillitis, too, the heart should be repeatedly examined and upon 
the appearance of the slightest signs of endocarditis the patient 
at once put to bed. 

In septic, scil. ulcerative endocarditis occurring in the course Septic fori** 
of septicemia and puerperal pyemia, orthocresol, quinine and 
mercury bichlorid have been recommended. Very little at best 



50 



ACUTE ENDOCARDITIS 



Syphilitic 
form 



Rheumatic 
form 



Best 

Counter-irrita- 
tion 



Medicamen- 
tous treat- 
ment 



Aconite 



Digitalis 



can, however, be expected from any medicine in this disease. 
In view of the serions and usually hopeless character of this 
malignant form of endocarditis these remedies should, however, 
be tried, for it is always better at least to try a medicine that 
can do no harm than to stand by without doing anything and' 
lazily contemplate the death of the patient. The use of carbolic 
acid subcutaneously and intravenously will be found discussed 
at length in the Chapter on Malaria. Quinine and mercury 
bichloride may be given combined, the former as the sulphate or 
the hydrochlorate, in doses of from five to fifteen grains (0.3 to 
1 gm.) ; the latter in the close of one-thirty-second to one-sixth 
grain (0.002 to 0.01 gm.) in pill or capsule, preferably with milk. 

In the syphilitic form of endocarditis the ordinary antiluetic 
medication (see Section Syphilis) must be used. In the rheu- 
matic form salicylates combined with alkalies, or the alkaline- 
quinine treatment should be administered, preferably the latter 
in view of the possibility of myocardial complications in which 
salicylates do harm (see page 48). Salicylic medication, more- 
over, seems to exercise a less profound effect in rheumatic disor- 
ders upon the endocardium (and pericardium) than upon 
the serous membranes lining the joints. For the mode of ad- 
ministering salicylates, alkalies and quinine in rheumatic endo- 
carditis, I refer to the Section on Acute Articular Rheumatism. 

With endocarditic inflammation once fully established the 
treatment varies according to the stage of the disease. Through- 
out the course of the endocarditis absolute rest in bed should 
be enforced ; cold should be applied to the precordium, either 
by means of a Leiter coil or an ice bag, either continuously or 
with interruptions, the latter plan being generally preferable 
and less disagreeable to the patient. Early in the affection cup- 
ping, leeching or counter-irritation with iodine, blisters or plas- 
ters over the heart can do no harm. 

The medicamentous treatment in the beginning must be 
chiefly directed towards maintaining the tone of the heart and 
preventing cardiac insufficiency. Here the tincture of aconite, 
one to five drops given every few hours, is the best remedy, 
especially in sthenic cases when the heart beats fast and strong; 
for this drug quiets the heart, slows its action and reduces the 
blood pressure, in other words, relieves the heart of much strain 
and reduces its labor. Later, when the heart is beginning to 
fail and its action is accelerated but weak and irregular, and 
stasis or hydrops in different organs begin to appear, then 
digitalis should be used (see page 28). In early stages of the 
disease, therefore, aconite is the proper remedy; in later stages 



PERICARDITIS 51 

digitalis. It is clear that occasionally these drugs may have to 
be given together. 

No drug that we know of can produce absorption of the Absorption of 
vegetations on the valves of the heart after they have once the exudate 
formed. Chloride of ammonia, sodium carbonate and the iodides 
of soda and potash have all been recommended for this purpose; 
but the claims for these remedies have never been substantiated 
clinically, so that these drugs had better not be given in endo- 
carditis, especially as their administration may do more harm 
than good by irritating the stomach and interfering wih diges- 
tion. Iodides have a place in chronic endocarditis, not on ac- 
count of their effect upon the vegetations but for their effect 
on the blood pressure (see page 55). 

The diet in acute endocarditis should consist largely of milk, Diet 
gruels and broths, with the additions of a little toast, a few 
crackers, a little fresh fruit and vegetables. 

During convalescence, in view of the valvular heart lesions 
that usually remain, the treatment becomes the same as in com- 
pensated or decompensated valvular lesions of the heart and I 
refer to those chapters for the details. 



PERICARDITIS. 

The treatment of pericarditis varies according to the stage 
of the disease and the character of the effusion or exudate in 
the pericardium. Upon the appearance of the first symptoms c id 
of pericarditis absolute rest in bed, with an ice bag or a Leiter Quinine 
coil over the heart, should be enforced; five to fifteen grains (0.3 Morphine 
to 1 gm.) of quinine should be administered in divided doses; 
and if the pain is very severe a fourth of a grain of morphine 
hypodermically, two or three times a day for two or three days. 
If the case cannot bear cold to the precordium, a warm Priess- Warm Priess- 
nitz compress should be applied, consisting of a linen cloth mtz com " 
wrung out of hot water and covered with several layers of 
flannel. This should be left on undisturbed for several hours 
and then renewed. Oatmeal or bread poultices, belladonna or 
veratrine plasters or ointments also often relieve the pain. Cold piasters and 
or heat or counter-irritants applied in this way to the precor- poultices 
dium produce dilatation of the cutaneous blood vessels of this 
area and hence relieve the congestion in the underlying peri- 
cardial sac; they also reflexly deplete the pericardium. These 
measures usually promptly relieve at least the disagreeable sub- 
jective sensations of the patient. 

The diet in the early stage should be non-irritating and Diet 
should consist of liquids, milk, gruels, possibly with the addi- 



PERICARDITIS 



Digitalis 



Diuresis and 
catharsis 



Paracentesis 
of the peri- 
cardium and 
pericardiotomy 



tion of a little toast, bread and butter or some stewed fruit or 
vegetables. 

No medicines can act directly curatively. In the tuberculous 
variety ideal hygienic conditions and a proper diet, as described 
in the Chapter on Tuberculosis should be insisted upon. 

In the rheumatic forms of pericarditis an alkaline salicylate 
treatment (see page 550) may occasionally aid in preventing 
pericarditis, but upon the establishment of pericardial inflam- 
mation the use of salicylates should be discontinued and quinine 
and alkalies (see page 552) given instead. 

In early stages if the patient is not weakened by disease, and 
if the heart's action is rapid and tumultuous, aconite is the best 
remedy, preferably given in doses of from one to five drops of 
a good tincture, every two or three hours. Digitalis should be 
given with care, especially in pericarditis with large amounts of 
effusion, because digitalis prolongs the diastolic dilatation of 
the auricles and this particular action of the heart is always 
rendered difficult when pressure is exercised upon it from with- 
out, as, for instance, by a large pericardial exudate. If digi- 
talis is administered at all the pulse should be carefully watched. 
In very advanced degrees of pericarditis, in which the heart's 
action becomes seriously impaired from excessive labor imposed 
upon the organ, digitalis and occasionally analeptics must be 
employed as an emergency measure in order to save life. If it 
becomes very slow, 65 beats to the minute or below, or markedly 
dicrotic, digitalis should be discontinued at once. Digitalis^ 
however, has a place in the treatment of early stages of peri- 
carditis without much effusion, for here it is very important 
that the heart's action should remain as energetic as possible,, 
because in this way the formation of fibrinous adhesions may be 
rendered difficult and possibly prevented. 

The treatment of large pericardial exudates that form after 
the acute stage of the disease is over, or of pericarditis that sets 
in with a large serous exudate, must be considered separately. 
Here an energetic diuretic treatment, as discussed under the 
heading of cardiac dropsies (see page 42), combined with cathar- 
sis, may be employed with the object of ridding the organism 
of much water through the kidneys and bowel, thus concen- 
trating the blood and consequently promoting the reabsorption 
of the pericardial exudate. Only occasionally, however, can 
pericardial fluid be made to disappear in this way. 

In case medical measures fail, then surgical treatment must 
be instituted, consisting either in paracentesis of the pericar- 
dium or pericardiotomy. The latter measure should always be 
adopted if the fluid contained within the pericardial sac is puru- 



ARTERIOSCLEROSIS AND CHRONIC AORTITIS 53 

lent. Here the pericardium should be broadly incised and free 
drainage established. This procedure must be carried out by a 
surgeon and the details need not be discussed in this book. 

Puncture of the pericardium, however, is a task that every 
internist should be able to perform. The skin is carefully shaved 
and rendered aseptic by scrubbing with soap and water, one 
to two thousand bichloride solution, alcohol and ether. The tro- 
car should be inserted either in the fifth or the fourth intercostal 
space on the left side about an inch from the left sternal margin. 
This point is selected in order to avoid wounding the mam- 
miliary vessels. It is usually best to use a local anesthetic, for 
instance an ether or chloride of ethyl spray, and to make a small 
incision at the point where the trocar is to be inserted. The 
nature of the operation should always be explained to the pa- 
tient in order that he may remain quiet, exercise self-control and 
co-operate with the physician. The patient will usually have 
to be operated upon in a semi-recumbent position; if it is at 
all possible, however, he should be laid flat on his back. In order 
to avoid injuring the heart the needle should be introduced at 
first directly backwards and then backwards and downwards 
very slowly and carefully and not, as in paracentesis abdominis, 
quickly. The fluid should be withdrawn gradually and a hypo- 
dermic injection of ether or camphorated oil be given while the 
fluid is being removed. The operation is not without danger 
and should only be resorted to as an emergency measure when 
all other means have failed; for cases are on record in which 
the heart was injured and death occurred during the operation. 
Puncture of the pericardium from the xiphoid angle on the left 
side by inserting the trocar upwards and backwards is still more 
dangerous and can only be carried out with relative safety in 
enormous pericardial exudates. 

II. THE ARTEKIES. 
ARTERIO-SCLEROSIS AND CHRONIC AORTITIS. 

Arterio-sclerosis in the majority of cases is the result of Causal treat- 
premature or normal senility. Causal treatment, therefore, in ment 
this category is self-evidently impossible. A small minority of 
the cases of arterio-sclerosis and chronic aortitis are due tc 
metabolic disorders, viz., gout, diabetes and obesity, or to cer- 
tian chronic intoxications and chronic intestinal derangement, 
to the abuse of alcohol, tobacco and lead, and, above all, to 
syphilis. The causal treatment of all these forms of arterial 
.degeneration is synonymous with the treatment of the un- 
derlying conditions, and will be discussed in their appropriate 
parts. 



54 



ARTERIOSCLEROSIS AND CHRONIC AORTITIS 



Symptomatic 
treatment 



Diet 



Reduction of 
calcium salts 



Lactic acid 
therapy 



Restriction of 
liquids 

Bathing 

Climate and 
altitude 



Symptomatic treatment must be directed chiefly towards 
preventing the over-tension of the peripheral vessels, in other 
words, towards keeping down the blood pressure. For the dis- 
eased arterial walls, owing to their lack of elasticity, determine 
high pressure and the high pressure in its turn presumably pro- 
duces further degeneration of the arterial museularis. It is 
hard N to say in many of the cases which was the primary event, 
the high tension of the blood or the arterial degeneration, i. e., 
the sclerosis. The dietetic rules to be observed are the follow- 
ing : Alcoholic beverages and tobacco, as well as tea and coffee, 
should either be forbidden altogether or should be allowed only 
very moderately. Meat should be reduced to a minimum, and 
particularly those varieties of meat and meat preparations ex- 
cluded from the diet that are known to contain extractives, 
for the latter raise the blood pressure (see page 20). A diet 
consisting largely of milk and plenty of fresh fruits and vege- 
tables, cereals and a moderate amount of fats is the best. In 
so chronic a disorder as arterio-sclerosis care must, above all 
things, however, be taken to maintain general nutrition. 

As one of the characteristics of arterio-sclerosis is calcifica- 
tion of the arteries, it has been suggested that the ingestion of 
calcium should be reduced by excluding from the diet articles 
of food containing this element; chief among them eggs, cheese, 
rice, asparagus, carrots and milk. It will be seen that, on the 
basis of this theoretical postulate, a milk diet would be dan- 
gerous and a meat diet permissible. Practical experience 
teaches, however, that patients with arterio-sclerosis thrive very 
much better on a diet consisting largely of milk and the other 
articles enumerated above than on a meat diet, hence the decal- 
cification plan, however seductive it may appear on theoretical 
grounds, is not practical. The suggestion has been made to 
counteract the deposit of calcium salts by the administration of 
lactic acid by mouth, and it can do no harm to adopt this plan, 
especially as lactic acid acts as an intestinal antiseptic and may 
be useful from this point of view. Lactic acid may be adminis- 
tered in the form of sodium or strontium lactate, in the dose 
01 fifteen to twenty grains (0.1 to 1.2 gin.) three times a day, 
or as lactic acid in solution in syrup (1:20) a teaspoonful three 
or four times a day. 

The ingestion of liquids should be somewhat restricted, for 
similar principles obtain here as in the treatment of compen- 
sated heart lesions (see page 21). The same applies to bathing 
and other hydrotherapeutic means, and the choice of a resort, 
climate and altitude. For the considerations that should gov- 
ern us in advising our patients in regard to these elements of 



ARTERIOSCLEROSIS AND CHRONIC AORTITIS 00 

the treatment I therefore refer to Compensated Heart Lesion 

(page 24f). 

The medicamentous treatment of arterio-sclerosis consists, 

first, in the use of the iodides, either of potash or sodium. Iodides of 

potash, and 
Iodides have long enjoyed a great popularity in the treatment so da 

of this disorder, and there is no doubt that empirically they act 
beneficially in arterio-sclerosis. It seems very doubtful whether 
iodides can, in any way, cause regeneration of the sclerotic ar- 
terial walls, as some writers claim. They certainly, however, 
keep the blood pressure low and this, as I have explained above, 
may aid Nature in partially restoring normal conditions. 
Iodides, according to the investigations of Romberg, presumably 
produce this effect by reducing the viscosity of the blood, in other 
words, rendering it more fluid without diluting it. This is a 
very useful influence, for in arterio-sclerosis, owing to the rigid- 
ity of the arteries and the narrowing of their lumen, the pro- 
pulsion of the blood is always impeded; if now the blood vis- 
cosity can be reduced it will flow more readily through the 
arteries and this factor, by relieving the heart of much labor, 
reduces the blood pressure. The iodides, moreover, exercise a Dose and ad- 
very striking effect upon the subjective symptoms of the pa- 
tient, especially the neurasthenic manifestations, the angina, 
the dyspnea, and the cardiac asthma. In order to be effective 
they should be given for long periods of time, preferably for 
years. In the beginning small doses, i. e., two to ten grains 
(0.12 to 0.6 gm.) should be given three times a day and the dose Alkalies 
later increased a little. In order to enforce the effect of the 
iodides, they should be administered in combination with some 
alkali, preferably the bicarbonate of soda, or dissolved in some 
alkaline water. A very useful method of administering them 
is to give two to ten drops of the saturated solution of iodide 
of sodium in a glass of milk, to which is added one-third of a 
tcaspoonful of bicarbonate of sodium. Iodides are best given 
after a meal; they should never be administered together with 
acid foods, nor to patients suffering from g'astric catarrh, and 
should never be administered in a metal spoon. In order to 
prevent the development of iodism the administration of the 
iodides should be interrupted from time to time, and a very 
good plan is to give them for three weeks consecutive, then to 
stop their use for one week and later possibly to omit them for 
two or three weeks at a time. 

For the purpose of reducing the blood pressure, the nitrites Nitrites 
may also be used; they are best administered in the rojt/n of 
nitrates combined with sodium bicarbonate, as the nitrates un- 
dergo reduction to nitrites in the body. Lauder Brunton, who 



56 



ANEURISM OF THE AORTA 



first advocated this treatment, recommended the following 
formula : 



i* 



Potassium bicarbonate, 1.8 

Potassium nitrate, 1.2 

Sodium nitrite, 0.03 

To be given in half a litre of water, early in 
the morning, on an empty stomach. 



Nitroglycerin 
and amyl 
nitrite 



Heart tonics 



Truneczek's 
serum 



Anti-sclerosin 



Or nitrite of soda may be given in tablets or solution in the 
dose of one to two grains (0.05 to 0.1 gm.). 

Nitroglycerin and amyl nitrite are of very subordinate im- 
portance in the treatment of arterio-sclerosis. They are chiefly 
useful to relieve paroxysms of angina pectoris, or to stop the 
retro-sternal pain that is so distressing a symptom in chronic 
aortitis. This pain is also materially relieved by the applica- 
tion of the ice bag, poultices and counter irritants to the precor- 
dial region. 

Heart tonics should be given with care in arterio-sclerosis, 
on account of the inability of the arteries to adapt themselves 
rapidly to blood pressure changes. In later stages of the dis- 
ease, however, when the heart has become insufficient and the 
blood pressure is low, digitalis, administered continuously in 
small doses, has its place. Groedel, than whom there is probably 
no greater authority on this subject, speaks very warmly of 
this practice and claims never to have seen any deleterious 
effect from it. 

Of late years Truneczek has described a serum to be used 
in arterio-sclerosis, and Goldschmidt a preparation called anti- 
sclerosin. Some good results are reported from the use of these 
remedies, but it is too early to pass judgment on their efficacy. 



Causal treat- 
ment 



ANEURISM OF THE AORTA. 

Aneurism of the aorta occasionally undergoes spontaneous 
cure by the deposit of coagulates of fibrin within the aneurismal 
sac. All causal treatment that we can employ for the cure of 
aneurism must, therefore, be directed towards aiding Nature in 
producing such coagulates. In order to fulfill this purpose an 
endeavor must be made to cause retardation of the blood stream 
and a reduction of the blood pressure, and if possible, a decrease 
of the blood volume, for all these factors favor coagulation. 



ANEURISM OF THE AORTA 0/ 

Absolute rest in bed for many months at a time is the ortho- Rest 
dox treatment of this disease. When this plan is adopted, the 
contractions of the heart are reduced by many thousands in the 
twenty-four hours. Thus Baumler, for instance, showed in a 
case of aneurism that the pulse fell from 95 to 56 after forty 
minutes of absolute rest. This means the elimination of 43,200 
contractions of the heart in twenty-four hours. 

The amount of food and drink should always be reduced in Diet 
-order to decrease both the blood volume and the blood pressure. 
It is never, however, a good plan to chronically underfeed these 
-cases, for a starving organism cannot develop full regenerative 
powers. As the patients are resting and quiescent the daily 
food requirement is eo ipso less; but in order to be perfectly 
■safe it is always best to submit these cases, after they have been 
in bed for a number of days and their metabolism has adjusted 
itself to the new conditions, to a careful metabolic study, in 
•order to determine what the minimum amount of food is that 
the patients require to maintain nutritive equilibrium. The 
technique of such an examination will be found described in 
the Chapter on Diseases of Metabolism. 

The selection of the diet should be governed by the same 
principles that obtain in myocarditis and arterio-sclerosis. Large 
meals that can overload the stomach, or articles of diet that un- 
dergo fermentation and hence can distend the stomach, thus 
pressing the diaphragm upwards and interfering with respira- 
tion and the work of the right heart, should always be avoided. 
If full feeding is permitted, therefore, the patient should receive 
small meals at frequent intervals. 

One of the most popular dietetic schemes employed in the Tufnell diet 
treatment of aortic aneurism is the regime arranged by Tufnell. 
His diet is altogether inadequate to properly nourish the pa- 
tients; and while he obtained remarkable success in some cases, 
it is, nevertheless, a precarious matter to adopt so low a diet 
scheme as a routine. Tufnell advised restricting the total amount 
of solid food to 300 grammes in the twenty-four hours and the 
liquids to 240 cubic centimeters. This ration he allowed to be 
slightly increased if the patient became excited and very much 
dissatisfied with the restricted regime. The meals were arranged 
as follows: 

For breakfast : 50 cc. of milk or cocoa with 60 grammes 
of bread and butter. 

For dinner: 90 grammes of meat and 90 grammes of bread 
or potatoes and 120 cc. of water or very thin claret. 



58 



ANEURISM OF THE AORTA 



More liberal 
feeding 



Restriction of 
liquids 



Free evacua- 
tion of the 
bowels 



Massage of 
the lower ex- 
tremities 



Medicamen- 
tous treat- 
ment 



Iodides 



Gelatine 



Fcr supper: 60 cc. of weak tea and 60 grammes of bread 
and butter. 

It is unnecessary to carry the restrictions so far, as equally 
good results are obtained with more liberal feeding, especially 
if a metabolic study precedes the arrangement of the dietary. 
Tufnell's scheme is, therefore, mentioned chiefly on account of 
its historical interest and because he deserves the credit of hav- 
ing first established the principle of restricted feeding in the 
treatment of aortic aneurism. 

It should rarely be necessary to reduce the liquids to less 
than 1,000 cc. in twenty-four hours. When the liquids are 
greatly reduced the patients naturally suffer from thirst; this 
distressing symptom can frequently be relieved without undue 
increase of the liquid intake by swallowing small pieces of 
cracked ice ad libitum, or by chewing gum. 

Care should always be taken to promote free evacuation of 
the bowels, because " straining at stool is always a precarious- 
matter in aneurism of the aorta, and the abdominal plethora is to- 
be avoided besides. The lower extremities of the patient should 
be kept warm and the legs and abdomen frequently massaged; 
these measures act beneficially, because both the heat and the 
massage reduce the peripheral blood pressure and draw muck 
blood away temporarily from the region of the aneurism. 

The medicinal treatment of aneurism of the aorta is of very 
subordinate importance. The iodides of potassium and sodium 
are used extensively. It is very doubtful, however, whether 
they exercise" any influence whatsoever upon the progress or 
regress of the aneurism itself. Symptomatically, they often stop 
the pain in the precordium and the left upper extremity. They 
should be given in increasing doses, preferably beginning with 
five drops of the saturated solution three times a day and grad- 
ually increasing the dose until thirty or forty grains are being 
taken daily or the desired effect is produced. The same prin- 
ciple and technique should govern the administration of iodides, 
in aneurism of the aorta as in arterio-sclerosis. (See page 55.) 

The subcutaneous injection of gelatine has recently been 
recommended in the treatment of aneurism, and the claim has 
been made that gelatine administered in this way increases the 
coagulability of the blood, and hence favors the deposit of fibrin 
within the aneurismal sac. As gelatine is made from the hoofs 
of animals, there is always some danger of its containing spores 
of tetanus, and hence the gelatine solution should be very care- 
fully sterilized before it is administered, as very disagreeable 
accidents have happened when this precaution was omitted. One 



ANEURISM OF THE AORTA 59 

of the best solutions to use for sub-cutaneous injection is the 
following : 

r> 

Gelatine, 1.5 gm. 

Sodium chloride, 0.1 gm. 

Distilled water, 100.0 cc. 

M. Sig. : To be sterilized by discontinued sterilization and 
injected warm in doses of 20 to 30 cc. on four or five 
successive days. 

The injections are best made in the gluteal region. They 
are frequently followed within a day or two by severe pain in the 
region of the puncture and occasionally by a rise of temperature. 
The pain may be relieved by local heat; the fever rarely lasts 
more than forty-eight hours and can be safely neglected. 

The results obtained from this practice have been sufficiently 
favorable in some cases, especially when combined with certain 
other local measures to be discussed below, to warrant its em- 
ployment, tentatively, at least, in sacculated aneurism. In the 
fusiform variety, or in dissecting aneurism, no good results have 
ever been published. One of the chief indices of the efficacy of 
gelatine injections is considered to be the disappearance of the 
radiating pains in the left upper extremity, signifying that the 
nerves of the brachial plexus have been relieved of some pressure 
on the part of the aneurism. A series of X-ray photographs may 
indicate ad oculos whether or not the size of the aneurism has 
been reduced. 

In addition to these hygienic, dietetic and medicinal measures, Surgical 
certain surgical means may be employed to advantage in the rea men 
treatment of aneurism, viz., in the order of their importance, 
galvano-puncture, acupuncture, filipuncture, proximal compres- 
sion (applicable only to aneurism of the abdominal aorta) and 
ligation of the carotid and subclavian. 

Galvano-Piincture is performed as follows : A fine insulated Galvano- 
needle is introduced into the aneurismal sac and connected with 
the anode of a galvanic battery. The cathode is attached to a 
sponge electrode that may be applied to the chest or the abdomen. 
Some authorities recommend inserting two needles into the 
aneurismal sac, the one connected with the anode, the other with 
the cathode. The former plan, however, is simpler and safer and 
produces the same results as the latter. The current should not 
be stronger than from ten to twenty milliamperes, and it should 
not be applied for longer than from fifteen to twenty minutes. 
It is well to test the coagulating power of the current before th-r 
needles are introduced into the aneurism, and this can be done 



60 



ANEURISM OF THE AORTA 



as follows: The white of an egg is poured into a dish and the 
needles inserted into it. When the current is turned on a firm 
clot should form at the positive needle while a frothy clot forms 
at the negative pole. 

Before the needles are introduced into the aneurism the 
patient should be told what it is intended to do, so that he may 
intelligently co-operate with the physician and exercise all his 
will power in remaining absolutely still. When the treatment is 
over, the needles are rapidly withdrawn and the little wound 
closed with collodion or court plaster. As a rule it is necessary 
to repeat this treatment two or three times at intervals of a week 
or so. There is always some danger of hemorrhage, and the 
possibility of embolism can never be excluded. A cure from 
this treatment is exceedingly rare, but quite a number of cases 
of aneurismal swellings have been reduced in size and the pain 
ameliorated. 

Pilipuncture Filipuncture consists in introducing fine needles into the 

aneurismal sac, as above, and scarifying the intima of the opposite 
wall. The roughening of the intima is intended to favor the 
deposit of fibrin and coagulates. A few cases of symptomatic 
improvement but no cures are reported from this treatment. 

Acupuncture Acupuncture consists in the introduction of iron or silver 

wire, horse-hair, silk thread or cat-gut into the aneurism, the 
object being to cause the precipitation of fibrin around these 
threads. As a rule, the pieces are only a few millimeters long; 
threads and wires several centimeters long have been introduced, 
however, without untoward results, but, unfortunately, also with- 
out particularly favorable effects. As this operation is very sim- 
ple and seems to be practically devoid of danger, and as it occa- 
sionally does some good, it may be employed, but only in des- 
perate cases, in which all other means have failed. 

Compression In aneurism of the abdominal aorta situated low down, com- 

pression of the aorta between the heart and the aneurism has 
been attempted; the object being to cause retardation and stasis 
of the blood stream in the aneurismal sac and thereby creating 
conditions that favor coagulation and hence obliteration of the 
aneurismal cavity. This procedure must, of course, be carried 
out under an anesthetic. The duration of the operation must 
vary according to the reaction of the patient, but in order to 
exercise any effect compression should be continued for several 
hours. The amount of pressure should be so great as to cause 
disappearance of pulsation in the sac. The operation may be 
repeated. The results reported are not particularly favorable 
and untoward consequences have occasionally been observed, for 



ANEURISM OF THE AORTA 61 

instance, peritonitis and mechanical lesions of the duodenum, the 
pancreas and the celiac plexus from the pressure. 

Ligation of the common carotid and the sub-cl avian artery Ligation of 
has been used as a desperate resort, but no good results are re- subclavian 
ported from this operation. It is mentioned merely for com- arteries 
pleteness' sake and on account of its historical interest. 

That these various surgical measures must be combined with 

rest and a restricted diet, possibly the use of iodides and gelatine, 

(see above), need hardly be emphasized. 

The symptomatic treatment of aortic aneurism concerns itself Symptomatie 

treatment 
chiefly with the relief of pressure symptoms. Chief among these 

are pain radiating in various directions according to the location 
of the aneurism and the nerve branches compressed ; venous con- 
gestion in various organs of the body, chiefly the head and arms 
in aneurisms of the upper aorta; dyspnea from compression of 
the trachea or from congestive bronchitis or from bilateral ab- 
ductor paralysis (pressure on the recurrent laryngeal nerve at 
the aortic arch). 

For the relief of the pain the ordinary anti-neuralgic remedies Relief of pain 
may be employed. For the pain produced hy the aneurism itself 
the ice bag or a Leiter coil to the precordium may be used, as de- 
scribed in the part on Pericarditis (page 51). Occasionally a 
narcotic or anodyne ointment applied to the chest relieves the 
pain. A very useful prescription for such an ointment, rec- 
ommended by Ortner, is the following: 

Menthol, 2.0 gm. 

Cocaine muriate, 0.2 gm. 

Morphine, muriate, 0.4 gm. 

Olive oil, 1.0 cc. 

Lanolin, 2.0 gm. 
M. Sig: Apply locally. 

For the dyspnea due to pressure hyperemia of the trachea or Dyspnea 
bronchial mucosa, the ordinary remedies for bronchitis should 
be employed (see Section Bronchitis). The same precaution in 
the selection of expectorants should be observed, however, as in 
the treatment of the bronchitis due to venous stasis in decompen- 
sated heart lesions (see page 38), and particular care should be 
exercised to avoid the administration of emetic expectorants, 
chiefly ipecac, because the strain of vomiting is always danger- 
ous in aneurism. 

Bleeding is a very useful measure in aneurism because it Bleeding 
rapidly relieves the congestion and generally stops the pain. 



62 



ANGINA PECTORIS 



Pressure 
symptoms 



This applies particularly to the disagreeable congestion occurring 
about the face, head, neck and upper extremity ; here bleeding is 
without doubt the sovereign remedy for producing symptomatic 
relief. 

disagreeable symptoms resulting from the pressure of the 
aneurism on the vagus or the phrenic nerve must often be re- 
lieved symptomatically by the use of opium or bromides and 
occasionally, in emergencies, by whiffs of chloroform. Sometimes 
it may become necessary to perform tracheotomy in order to 
relieve laryngeal dyspnea due to bilateral abductor paralysis, 
resulting from pressure of the aneurism upon the laryngeal 
nerves. 



Causal treat- 
ment 



Prophylaxis 



Diet 



III. NEUROSES OF THE HEART. 
ANGINA PECTOEIS. 

Angina pectoris is, in most cases, due to ischemia of the 
heart muscle. The factors that determine an inadequate sup- 
ply of blood to the heart are manifold, and may be either organic 
or functional in character. In most instances angina pectoris 
is a symptom of a general arterio-sclerosis involving the coronary 
arteries and, possibly, also the endocardium; in other cases it 
appears that the coronary arteries alone are sclerotic, and, in 
still other cases, there is an aortitis, due to different causes, pro- 
ducing mechanical narrowing of the orifices of the coronary ar- 
teries in the aortic wall; or there may be thrombosis or em- 
bolism of these vessels. Besides, spasmodic contraction, of the 
walls of the coronary arteries, due to a variety of possible neu- 
rotic causes, may occur. Finally, there is also a symptomatic 
form, so-called pseudo-angina, that occasionally develops on the 
basis of a neurasthenic or hysterical condition. 

The causal treatment of angina pectoris must, therefore, take 
all these different possibilities into consideration. Thus all the 
factors that can become operative to produce arterio-sclerosis 
or arteritis (see page 53) should be treated provided any early 
evidence of arterial degeneration is determinable. Every case 
of angina pectoris should be given the benefit of an antiluetic 
treatment. If the patient is manifestly neurotic then appro- 
priate hydro-therapeutic, medicinal and rest treatment, as de- 
scribed in the Section on Gastric Neuroses, should be instituted. 

As a means of prophylaxis the diet should be arranged in 
such a way that all principles capable of exciting the heart and 
raising the blood pressure are eliminated. Meat extracts and 
bouillons, raw, rare, cured and smoked meats, internal organs, 
tea and coffee should all be forbidden because they contain ex- 
tractives (purin bodies) that notoriously irritate the heart. Alco- 



ANGINA PECTORIS 63 

hoi should be used with the greatest care, and smoking, even 
prolonged sojourn in a smoke-laden atmosphere, should be inter- 
dicted. Very hot and very cold beverages, spices, carbonated 
waters, should all be forbidden and all distension and over- 
loading of the stomach carefully avoided, as otherwise reflex 
and mechanical irritation of the heart from the stomach may 
result. Other exciting causes to be avoided are sudden physical 
exercise, and especially quick movements of the left arm and 
left upper extremity. 

Unfortunately, the majority of cases of true angina pectoris 
are not recognized until the degeneration of the aorta and the 
coronary arteries has become irremediable. In such cases one 
is limited to regulating the patient's mode of life in such a 
way that all causes that can notoriously precipitate an attack 
are eliminated. If one could begin early, even with the prophy- 
lactic treatment, much would be gained, but unfortunately early 
manifestations of angina pectoris are usually misinterpreted, 
owing to the mild and transitory character of the attacks, and, 
above all, to the peculiar tendency of anginal pains to radiate 
into remote parts of. the body, thus simulating neuralgias of 
various parts, lumbago, renal and hepatic colic or gastralgia. 

For all these reasons the treatment of angina pectoris is in 
most cases symptomatic and limited to aborting or relieving 
the paroxysms. The pain is excruciating and the sense of im- 
pending death horrible. The ordinary analgesic remedies are Vaso-dilators 

altogether too slow in their action to have a place in the treat- in ^g" 31 P res ~ 

° ^ sure angina 

ment of acute attacks of angina pectoris. As hypertension is 

present in most cases of angina pectoris the use of vaso-dilators 

is generally indicated. Here the character of the pulse and, 

above all, of the second aortic sound, should be carefully but 

quickly studied. If the pulse possesses the characteristics of a 

high tension pulse^and if the second aortic sound is markedly 

accentuated, then the use of vaso-dilators and anti-spasmodics 

is always indicated. 

This study of the heart and blood pressure need, generally, 

only be performed during the first attack, chiefly to 

determine whether one may not possibly be dealing with a case 

of angina pectoris due to advanced myocarditis, or to aortitis 

without general arterio-sclerosis ; for, in such cases the anginal 

attack may be due to, or may be complicated by, acute dilatation 

of the heart, with low arterial tension, as indicated by a weak cardiac tonics 

second aortic sound, possibly murmurs (due to relative, i. e., in low pres- 

muscular insufficiency), a correspondingly low radial pulse and angina^ 6 

a weak apex beat. In this latter class of cases treatment 

directed against high tension is wrong; digitalis and other 



G4 



ANGINA PECTORIS 



Nitrites 



Amyl nitrite 



Morphine 



Chloroform 



Applications 
to the pre- 
cordium 



interim 
treatment 



Nitroglycerin 



cardiac tonics and pressure-raising remedies are indicated, and 
not vaso-dilators; the latter, in fact, do much harm, fail to re- 
lieve the symptoms, and may even determine death. 

Excepting in this comparatively rare class of cases, how- 
ever, the nitrites are the remedy of choice. Amyl nitrite is. 
deservedly the most popular remedy in angina pectoris. The 
drug is best dispensed in glass pearls containing three to five 
drops of amyl nitrite; patients suffering from angina pectoris 
should carry these pearls with them. Upon the appearance of 
the attack or of premonitory symptoms, such as pain radiating 
into the left arm, one of these pearls should be broken in a 
handkerchief and the vapors inhaled. The vaso-dilator effect 
becomes apparent almost instantaneously, the face becomes 
flushed and the head feels full. If the attack is not stopped by 
the first inhalation, two, three or four pearls full of amyl nitrite 
should be inhaled at short intervals. 

If this treatment fails to stop the agonizing pain, then re- 
course must be had to morphine, a drug that acts favorably in 
this condition, both by its vaso-dilator effect and its tendency 
to reduce the blood pressure. It should be given hypodermically,. 
in doses of at least one-fourth to one-half grain (0.016 to 0.03 
gm.) repeatedly. Theoretically, repeated doses of morphine 
are contra-indicated in cases of general arterio-sclerosis suffer- 
ing from angina pectoris, in which there is arteriosclerotic de- 
generation of the kidneys, because, under these circumstances^ 
the drug is eliminated so slowly that a dangerous cumulative 
effect may be produced; but this will be a rare event. Inas- 
much as morphine exercises its influence very much more 
slowly than amyl nitrite, it is best to administer a hypodermic 
of morphine as soon as the attack begins and while the amyl 
nitrite is being inhaled, for in this way valuable time may be 
saved. * 

In case neither amyl nitrite nor morphine relieve the pain r 
then chloroform should be given, preferably by inhalation. This 
is, of course, a somewhat precarious procedure in any form of 
heart disease and hence this plan should only be adopted as an 
extreme emergency measure. 

Locally, hot applications, poultices or a mustard plaster to 
the precordial region may be of some benefit ; counter-irritation 
of this kind should always be attempted, but only in addition 
to the other measures enumerated. 

In the interim between attacks, and in a sense as a prophy- 
lactic measure, nitroglycerin and nitrites may be given; to be 
efficacious, however, they should be given continuously. Nitro- 
glycerin may be administered either in the form of one one- 



PALPITATION 65 

hundredth to one one-hundred-and-fiftieth grain tablets, two or 
three times a day, or preferably in the form of a one per cent, 
alcoholic solution, beginning with one drop of this three times 
a day and increasing the dose a drop every four or five days 
until flushing and headache appear. The dose should then be 
reduced a drop or two and the patient kept continuously on this 
amount. From time to time the dose should again be increased 
until flushing and headache appear; and it will be found that 
after a time more can be tolerated than at the beginning. 

A preparation of nitroglycerin that has recently attained Erythrol 
well deserved popularity is erythrol-tetranitrate. This remedy 
grants a more prolonged vaso-dilator effect than nitroglycerin. 
The fall in the blood pressure begins about half an hour after 
its administration and usually persists for three or four hours. 
It may either be given in tablet form in doses of one-twelfth 
grain (5 mg.) every four hours, or in the form of drop doses of 
a concentrated solution by mouth. Here, again, the appear- 
ance of flushing and headache indicate whether or not too much 
is being given. 

The nitrites, finally, should be administered in doses of three Nitrites 

grains (0.15 gm.) of sodium nitrite or potassium nitrite, three 

times a day, in milk or water ; or the formula of Lauder Brunton, 

given in the Section on Arteriosclerosis (see page 56) may be 

used to advantage. The use of iodide of potash has already been Iodide of 

n , potash 

mentioned above. 

Seizures of pseudo-angina pectoris, due to functional nervous 
disorders, and without evidence of arterio-sclerosis or myo- 
carditis, can often be successfully treated by cold and pressure 

over the precordium, and a strong mental suggestion. During 

Pseudo-angi- 
the paroxysm the administration of a teaspoonful of ether often nal paroxysms 

relieves at once. In the interim the underlying neurosal element 

must be attacked^ and all those general prophylactic measures 

instituted that are employed in true angina pectoris. 



PALPITATION. 

The disagreeable subjective character of palpitation makes 
it one of the most important symptoms to treat ; for patients are 
apt to worry more about it than about severe organic heart 
lesions that do not give rise to symptoms that are so noticeable. 
Palpitation may occur in organic heart disease, but more com- 
monly it is present when the heart is organically intact. In 
few conditions does successful treatment depend so much on 
a careful diagnosis. Organic disease of the heart, especially 



Introductory 



66 



PiVLPITATION 



Functional 
palpitation 



Organic ner- 
vous disease 



Exophthalmic 
goitre 



Anemia and 
malnutrition 



Chlorosis 



Early tuber- 
culosis 



Nephritis 



Intoxications 



Neurasthenia 
and hysteria 



fatty degeneration, dilatation and disease about the aortic 
valves, should always be carefully looked for. Congenital smail- 
ness of the heart and narrowing of the arteries are also import- 
ant findings. Palpitation in organic heart disease is always a 
sign of cardiac weakness and occurs chiefly when more work 
is suddenly thrown upon the heart than its reserve force can 
meet. 

In the majority of cases there is merely over-irritability of 
the heart and its ganglia without heart lesions, possibly over- 
action of the accelerator nerves of the heart (the sympathetic), 
or defective action of the inhibitory nerves (the vagus). These 
perversions of the action of the heart muscle and of the nervous 
apparatus of the heart may be purely functional, or they may 
be due to organic nervous disease. Hence particular care should 
be exercised to search for disease of the sympathetic or its gang- 
lia, and for disease of the central nervous system. To the same 
category also belong early cases of exophthalmic goitre; so that 
in every case of palpitation, the eyes and the thyroid should be 
carefully examined for evidence of Graves' disease. Inasmuch 
as exophthalmic goitre occasionally appears without exophthal- 
mos, and without goitre, the minor symptoms of this affection 
(the tremor, sweating, lid-signs, etc.) should be carefully looked 
for. , 

Palpitation may also be a part phenomenon of anemia or 
chronic malnutrition in which there is irritable weakness of the 
nervous apparatus governing the heart's action. Very import- 
ant in this respect is chlorosis, for here, as shown in another 
chapter, we have aside from the anemia, an unstable nervous 
system and very commonly congenital smallness of the heart and 
of the arterial capacity. 

In every case of palpitation the apices of the lungs should 
always be carefully examined for evidences of early tubercu- 
losis, for it is well known that in apical tuberculosis palpitation 
of the heart is very common. Whether this is due to a special 
toxemia or to irritation of the sympathetic fibres in the neck 
is undetermined. In nephritis, too, especially in the cardio- 
vascular type of renal disease ( Bright 's disease), palpitation is 
a common sign, hence the urine should always be carefully in- 
vestigated for the presence of renal elements, or albumen, and 
for renal inadequacy. 

Certain intoxications, notably by tea, tobacco, coffee, alco- 
hol and even heart tonics (digitalis, strophanthus, strychnia, 
when employed injudiciously), can all cause palpitation. 

Finally, there is a purely neurotic form that develops on 
the basis of neurasthenia or hysteria. Here exciting causes 



PALPITATION 67 

must be very carefully looked for. These may be external and 
consist of some sudden emotional shock, a fright, a loud noise, 
or a flash of light, etc., or they may be internal and reflex in 
character; thus indigestion, especially when associated with 
gaseous fermentation or flatulency, intestinal parasites, abdom- Reflex causes 
inal adhesions, gastro- and enteroptosis, disorders about the 
genital apparatus, especially the ovaries and uterus, hemorrhoids 
and abdominal plethora in general, may all reflexly, in predis- 
posed subjects, irritate the heart in such a way that palpitation 
is produced. Prophylaxis 

To prevent the attacks of palpitation the underlying cause 
must be treated. In palpitation resulting from over-exertion 
or fatigue, especially in individuals whose heart is congenitally 
small or whose arteries are narrow, or in subjects with a thorax 
paralyticus or a phthisical habit, the amount of exercise must 
be carefully regulated. Such individuals must learn how much Exercise 
physical exercise they can stand without developing palpitation 
and should carefully train the heart to increased labor by means 
of Schott and Oertel exercises or hydriatic means (see page 
23). Very hot baths, and, above all, Turkish baths, should be 
forbidden such subjects and the use of coffee, tea, alcohol and Bathing 
tobacco should be restricted or stopped. In phthisical patients 
particularly the administration of heart tonics and analeptics 
should be carried out very conservatively and preferably re- 
served only for emergencies. 

In palpitation occurring in organic disease of the heart in ^rDit^t" 11 * °'n 
subjects who are not neurotic, the treatment is synonymous with organic heart 
the treatment of the underlying cardiac disorder. One should isease 
constantly remember that palpitation is often an early sign of 
valvular disease so that the diagnosis of nervous palpitation 
should always be made very guardedly. Heart tonics judi- 
ciously administered according to the principles described under 
compensated valvular disease, especially when combined with 
drop doses of the tincture of aconite, will relieve the palpitation 
in these cases. 

If the palpitation is purely neurotic in type without organic Neurotic type 
disease of the heart a rest cure and appropriate hydro-thera- 
peutic measures, as lukewarm baths, are particularly valuable 
in reducing the frequency of the attacks. Suggestive therapy 
also helps. The patients should be carefully instructed in re- 
gard to the purely functional character of their heart symptoms 
and should be encouraged not to worry. All emotional or men- 
tal strain should be strenuously avoided. The patients should 
be instructed to reduce the use of tea, coffee, alcohol and to stop 
smoking;. Particular care should be taken to find possible re- 



68 



PALPITATION 



Diet in neu- 
rotic cases 



Drugs in neu- 
rotic cases 



Valerian 
Bromides 
Mux vomica 



flex causes for the palpitation, and, for this reason, the genital 
apparatus, the rectum and the nose should be carefully exam- 
ined and any abnormalities corrected; intestinal parasites should 
be looked for and removed; the function of the stomach and 
intestine should be regulated. The exact arrangement of the 
diet must depend on the functional state of the digestion and, 
for this reason, careful analyses of the stomach contents should 
be made from time to tjme and treatment instituted accord- 
ingly. No general rules can be formulated except that the meals 
should be small in order to prevent over-loading and distension 
of the stomach and should contain little carbohydrate in order 
to forestall fermentative dyspepsia, flatulency and meteorism. 
The food should never be too hot nor too cold, nor should it con- 
tain strong spices. 

In purely neurotic cases valerian and bromides are the most 
useful remedies for continuous use. Sodium bromide in ten to 
fifteen grain doses, two or three times a day, combined with the 
ammoniated tincture of valerian, one to three drachms (4 to 
12 ec), and the tincture of nux vomica five to ten drops, is a 
useful combination; or the pill of the three valerianates (Good- 
dell) may be used to advantage, viz: 



i? 



Quinine valerianate, 

Iron valerianate, 

Ammonium valerianate, aa 1 gr. (0.06 gm.) 

M. Sig. One such pill two or three times a day. 



Symptomatic 
treatment of 
the paroxysm 

Deep breath- 
ing 

Counter-irri- 
tation of the 
nasal mucosa 

Faradization 
of the vagus 



Counter-irri- 
tants to pre- 
cordium 



The treatment of the paroxysm does not differ materially 
from the preventive treatment, excepting that somewhat more 
energetic measures are employed. Any reflex stimulation of 
the vagus usually stops the paroxysm. This reflex stimulation 
may be produced by instructing the patient to breathe deeply; 
or by the use of smelling salts or iodo-glycerin applied to the 
nose on a probe; or by an indifferent alkaline nasal spray. In 
very severe cases faradization of the vagus and neck, as de- 
scribed in the Section on Exophthalmic Goitre (page 106) is often 
useful. 

Clothing that is tight about the chest and waist should be 
removed. A belladonna or mustard plaster may be applied 
to the precordial region. Better still is the application of cold 
in the form of an ice bag, for both the cold and the pressure 
upon the heart and, in hysterical cases, the suggestive effect, aid 
in quieting the heart; at the same time hot water bags may be 
applied to the feet and the legs vigorously rubbed. Some pa* 



PALPITATION 69 

tients of the neurotic type derive almost instantaneous relief from 
compression of the heart by means of a pelotte arranged like 
a truss, to be adjusted around the thorax as soon as palpitation 
occurs. Here, too, a suggestive element presumably plays an im- 
portant part. 

The medicamentous treatment in cases due to organic disease Cardiac 
of the heart consists in the use of strong cardiac stimulants (hot stimulants 
coffee, brandy, digitalis, camphor, ether, ammonia, see page 32. 
The special treatment of palpitation in compensated aortic in- 
sufficiency has already been discussed on page 19. If the blood 
pressure is very high, amyl nitrite may be inhaled. 

If there is no organic disease of the heart and no dilata- Aconite 
tion from over-exertion, then the tincture of aconite in drop 
doses every hour is the most efficacious remedy. Often in such 
cases a few whiffs of chloroform, or one-fourth grain of mor- chloroform 
phine, hypodermically, also stop the paroxysm promptly. So- Morphine 
dium bromide and chloral, ten grains of each, repeated every m ide 
hour and a half or two hours for two or three doses, will prevent clll oral 
the recurrence of the attack. This combination, too, is valuable 
as a prophylactic measure in nocturnal palpitation. Here, if 
given just before retiring, the restlessness and sleeplessness are 
allayed and the nocturnal attack of palpitation prevented. 

In purely hysterical cases the ammoniated tincture of vale- Valerian 
rian, one to three drachms (4 to 12 cc.) or asafetida, preferably Asaf etida 
given as the Aloes and Asafetida Pill in four to eight grain 
doses, occasionally stop the paroxysm. That a strong mental 
suggestion should be attempted in all cases of hysterical or 
neurasthenic palpitation need hardly be repeated. Very often 
a command on the part of the physician to exercise self-control 
will stop the palpitation. In other cases the repeated assur- 
ance that there is no danger, or soothing suggestions and, in 
extreme cases, hypnosis, may be more effective than a command. 

If the bowels are constipated when the attacks come on, or Catharsis 
if there is evidence of much abnominal plethora (hemorrhoids), 
meteorism or flatulency, a brisk saline cathartic, i. e., a table- 
spoonful of sodium or magnesium sulphate and a colonic flush- 
ing should be given. If there is evidence of acute distension Lavage of the 
or dilatation of the stomach, then evacuation of the stomach con- s omac 
tenets through a stomach tube followed by lavage (see index) 
often suffices without further medication to stop the paroxysm 
of palpitation. 



70 ARRHYTHMIA 



ARRHYTHMIA. 



Irregular heart action, abnormal slowness or rapidity of 
the heart, may either accompany a variety of organic disorders 
of the heart and arteries, chiefly myocarditis and dilatation oc- 
curring in the course of infectious diseases or of arteriosclero- 
sis ; or they may be a part symptom of some organic lesion of the 
nervous system or of a functional neurosis; or, finally, they 
may be the result of intoxication by alcohol, tobacco, coffee, lead, 
etc. The different varieties of irregular heart action, viz., in- 
termittent, paradox, bigeminal and trigeminal pulse, embryo- 
cardia, bradycardia, tachycardia, gallop-rhythm and delirium 
cordis must all be carefully analyzed and the underlying causes 
determined. If due to valvular lesions or myocardial or arterio- 
sclerotic changes, these conditions should be treated as described 
under those disorders. If due to cerebro-spinal disease (syphilis, 
sclerosis, gumma, hemorrhage), then large doses of iodides 
should always be given a trial. If due to a functional neurosis, 
then this should be treated, at the same time reflex causes in dif- 
ferent organs should be sought for and removed. Th3 toxic 
varieties self-evidently call for the withdrawal of the toxic 
agent. 

It will be seen, therefore, that the different forms of irreg- 
ular heart action call for similar causal treatment as palpita- 
tion. The symptomatic treatment is altogether identical with 
that of palpitation; in fact, the combination of arrhythmia and 
palpitation, especially tachycardia and palpitation, is the rule. 
For the details of this treatment I, therefore, refer to the Section 
on Palpitation. Slow pulse (bradycardia), it may be remem- 
bered, finally, is often a physiological phenomenon, in no way 
endangers the life of the patient and calls for no special treat- 
ment 



CHAPTER II. 

DISEASES OF THE BLOOD. 

I. THE ANEMIAS. 

The nomenclature and classification of the anemias is involved Nomenclature 
and confusing. Every anemia is characterized by a reduction 
of the hemoglobin (oligochromemia). Pernicious anemia is char- 
acterized by the appearance of morphological elements in the 
blood (megalocytes and megaloblasts) that are not normally 
present ; in other words, there is always a qualitative perversion 
of the blood-forming function, involving chiefly hemopoesis in 
the bone marrow (megaloblastic degeneration and reversion to 
an embryonic type). In simple anemia there is merely under- 
or over-activity of this function without qualitative perversion. 

Until recently the pernicious variety was called primary 
(progressive) anemia, and the simple variety, secondary anemia. 
This nomenclature is incorrect, for pernicious anemia is by no 
means always a disease sni generis, nor "idiopathic," but often 
like simple anemia directly traceable to definite and determinable 
causes; and simple, so-called secondary anemia not infrequently 
develops into pernicious, so-called primary anemia. 

For the sake of clearness, therefore, the anemias in this 
chapter will de discussed under the headings of progressive 
pernicious anemia, simple anemia and chlorosis; the latter dis- 
order presenting the blood picture of a simple anemia, but dif- 
fering from all other simple anemias, both in regard to its gene- 
sis, its blood pathology and its treatment, and hence calling for 
special and separate discussion. 



PROGRESSIVE PERNICIOUS ANEMIA. 

The causal treatment of pernicious anemia must consider Causal treat- 
many factors. Many cases of progressive pernicious anemia have ment 
been found to be due to the presence of intestinal parasites, nota- 
bly bothriocephalus latus, so that in all cases this intestinal 
parasite should be looked for, and removed, if it is found. Here Intestinal 
the results are brilliant, for this variety of pernicious anemia i mrasites 
is distinctly curable by removing the cause. Other parasites 
of the bowel can also be incriminated with producing pernicious 
anemia, and, for this reason, anthelmintics, administered as de- 



72 



PROGRESSIVE PERNICIOUS ANEMIA 



Autotoxemia 
from the 
bowel 



Gastric 
atrophy 



Blood para- 
sites 



Syphilis 



Pregnancy 



General 
hygiene 

Rest 
Diet 



Hydrotherapy 



Arsenic 



scribed under Diseases of the Intestines, should as a prelim- 
inary step always be given a full trial in every case of progress- 
ive pernicious anemia that comes under observation. There is 
also some evidence to show that other forms of bowel intoxication 
may occasionally produce pernicious anemia, and for this reason 
free evacuation of the bowel contents should be promoted in all 
cases by the administration of laxatives; the latter being to 
advantage combined with some of the intestinal antiseptics (see 
index). Still other forms of pernicious anemia develop as the 
result of atrophy of the gastric or intestinal glands, so that it 
is very important to make a careful analysis of the stomach con- 
tents to determine the state of the stomach function and to treat 
any perversion according to proper rules. Again, blood parasites, 
notably the Plasmodium of malaria, filaria sanguinis and distoma 
hematobium should be looked for and their removal attempted. 
Here quinine and other drugs as described elsewhere are the 
best remedies. Syphilis, toe, occasionally produces pernicious 
anemia and antiluetic treatment will lead to the goal more 
rapidly than any measures directed towards improving the con- 
dition of the blood symptomatically, although the prognosis, in 
syphilitic anemia of the pernicious type, is not favorable even 
under antisyphilitic medication. The same applies to the per- 
nicious anemia occasionally seen in pregnant women. Statistics 
show that even the induction of premature labor and the removal 
of the fetus exercise no beneficial effect on the pernicious anemia 
of pregnancy after it has once become established. 

Aside from all this causal treatment the general hygiene is 
very important. The patient should be put to bed and kept there 
for weeks until the blood picture improves, i. e., until a remission 
occurs. During the period of rest the diet should be arranged 
according to the condition of the stomach and bowel functions. 
A bland, non-irritating diet consisting chiefly of milk, cereals, 
eggs, fresh fruits and vegetables is usually well borne. The 
patients, as a rule, have a very strong aversion to meat, and meat- 
eating should not be forced, especially as the hydrochloric acid 
secretion in the stomach is usually greatly reduced in pernicious 
anemia. Hydro-therapeutic measures, on account of the weak- 
ened condition of the patient, the impoverished state of the blood 
and the deficient vaso-motor reaction, had better be omitted, at 
least during the active stage of the disease. 

The best remedy to administer in pernicious anemia is arsenic. 
This drug does not cure the disease, but it certainly aids in im- 
proving the condition of the blood, and hence in removing many 
ol the most distressing symptoms that are attributable to the 



PROGRESSIVE PERNICIOUS ANEMIA 73 

deficient nutrition of various organs, that results from the de- 
crease of hemoglobin in the blood. Arsenic may be administered Dose and ad- 
either in the form of Fowler's solution or as arsenious acid. It ministratl011 
is best to begin with small doses, gradually increasing them, and 
to keep the patient for a time just below the maximum dose that 
has been reached; then gradually to reduce the dose again. 
Some authorities advise beginning at once with large doses, but 
I have never been able to convince myself that this treatment is 
more efficacious or more rapid in its results; in fact, I consider it 
occasionally dangerous, in view of the possible idiosyncrasy of 
the patient against arsenic and on account of definite contra- 
indications to its use that may not be discovered until the drug 
is being administered. 

Such contra-indications are the existence of dyspeptic symp- Contra-indi- 
, . .,. , -, „ ., ., . . f 7 ., , cations to the 

toms and of diarrhea before the drug is given, or their develop- use of arsenic 

ment soon after its exhibition. In all these cases arsenic should 
be discontinued until the diarrhea is checked or the dyspeptic 
symptoms are relieved. Sometimes, in very urgent cases, these 
contra-indications to the use of arsenic may be neglected; care 
being taken that some measures are instituted that can counter- 
act the bad effects that we must expect from the use of the drug ; 
thus arsenic given by mouth with abundant quantities of fat is 
occasionally well borne; or the addition of opium to an arsenic 
preparation may sometimes effectually counteract the tendency 
to diarrhea. In treating patients in this way we are on the horns 
of a dilemma, and are simply choosing the least of two evils ; for 
it is often most important to use arsenic, even though distress- 
ing symptoms are produced by its administration. 

If Fowler's solution is used one should begin with ten drops Fowler's 
in water or milk, three times a day after eating, gradually in- so u 10n 
creasing the quantity by a drop a dose a day, i. e., by three 
drops a day. As a rule, this increase can be borne for about ten 
days, i. e., until the patient is taking sixty drops during the 
twenty-four hours. Occasionally symptoms of arsenic poisoning 
appear before the maximum dose is reached. The patients then 
complain of burning in the mouth, thirst, dyspeptic symptoms 
with eructations and pain in the epigastrium, some puffiness 
about the eyelids and the appearance of red blotches in different 
parts of the body. When such symptoms appear, the dose of 
arsenic should at once be reduced and occasionally it may even 
become necessary to stop the drug altogether until these symp- 
toms disappear. 

Arsenious acid is best given in the form of the so-called Asiatic pill 
Asiatic Pills, which contain some pepper. The latter stimulates 
the secretion of hydrochloric acid and aids in the rapid abs^rp- 



74 



PROGRESSIVE PERNICIOUS ANEMIA 



Arseniated 

mineral 

waters 



Hypodermic 
administra- 
tion of ar- 
senic 

Cacodylate of 
soda 



Iron not indi- 
cated 



Bone marrow 



Hemoglobin 



Transfusion 
of healthy 
blood 



Technique of 
transfusion 



tion of the arsenic, thereby, in a measure, preventing injury to 
the gastric mucosa by the drug. One should begin with one such 
pill a day, gradually increasing the dose until six, or eight, or 
ten pills are taken a day. This latter dose corresponds to about 
sixty to seventy drops of Fowler's solution. 

Still another method of giving arsenic, in case neither Fow- 
ler's solution nor arsenious acid can be borne, is to use arseniated 1 
mineral waters. A number of these waters are on the market 
(Lithico water, Roncegno, la Bourboule, Guberquelle and oth- 
ers). Most of these contain very small quantities of arsenic 
combined, as a rule, with iron. They should be administered at 
first in small quantities, preferably in tablespoon doses, gradually 
increasing the amount until a wine glass full, two or three times 
a day, is being taken. Their composition, however, is not con- 
stant and one is never sure of an arsenic effect when giving these 
waters. 

The hypodermic administration of arsenic is not to be advised 
in pernicious anemia, for disagreeable local symptoms are very 
apt to appear. The only arsenic preparation that can be given 
with safety is the cacodylate of sodium, in the strength of 1 to> 
500, in 10 cc. doses, once or twice a day. I have had the impres- 
sion, however, that this method of administering arsenic, useful 
though it may be in certain other conditions, notably chorea and 
leukemia, is of very subordinate value in pernicious anemia, and 
certainly inferior to the administration of arsenic by mouth. 

Iron is not indicated in pernicious anemia. My opinion is 
that it does more harm than good, for it seems to exercise no 
effect upon the constitution of the blood, while it usually irritates 
the stomach and disturbs the digestion. 

Bone-marrow was, at one time, employed in the treatment of 
pernicious anemia, but its use is being abandoned. I have never 
seen any good results from its exhibition. The same applies to 
the administration of dried blood or hemoglobin in solution by 
mouth or per rectum. 

In every advanced case of pernicious anemia, in which the 
patient is in imminent danger of his life, transfusion of blood 
from a healthy subject, or of physiological salt solution, or the 
injection of the latter by hypodermoclysis, are exceedingly useful 
measures. 

The transfusion of blood from a healthy individual to the 
patient should be performed as follows : A compression bandage 
is applied about the arm, both of the healthy individual and of 
the anemic subject and the anterior surface of the arm of each 
thoroughly cleansed with soap and water, 1 to 1000 bichloride 
solution, alcohol and ether; a hollow needle connected with a 



PROGRESSIVE PERNICIOUS ANEMIA 75 

thin rubber tube is now inserted into a vein of the healthy sub- 
ject and about 50 cc. of blood aspirated with a syringe. At the 
same time an assistant inserts a similar needle connected with a 
rubber tube into the vein of the patient, allowing a few drops 
of blood to ooze out of the tube, and then rapidly connects it with 
the syringe containing the blood from the healthy subject. This 
blood is now slowly injected into the veins of the patient, and 
the operation repeated four or five or six times in the course of 
five to twenty minutes. That everything should be rigidly sterile 
need hardly be mentioned. It is always safer to have a number 
of syringes ready, so that a new syringe can be used for each 
transfusion, otherwise there is always danger of coagulation 
occurring in the syringe or its nozzle, with the possibility of 
forcing a fibrin coagulate into the veins of the patient; such 
an accident would, of course, be fraught with very serious conse- 
quences. This method of transfusion is called the direct method. 

There is also an indirect method. It is more complicated, Indirect meth- 
less safe and not so easy of execution. It consists in withdraw- f us io n rans " 
ing about 400 cc. of blood from the normal subject by venesec- 
tion, rapidly defibrinating this blood by beating it with a glass 
rod, filtering off the clot and injecting the plasma through an 
ordinary transfusion apparatus into the veins of the patient. 
In performing this operation the canula leading from the trans- 
fusion apparatus must be tied into a vein in the patient's arm. 
This requires dissecting out the vein, a manipulation that calls 
for considerable skill and most rigid asepsis, and that, besides, 
is more painful than the insertion of a canula or trocar needle 
directly into the vein. 

Many patients react to this transfusion by a chill, a rise of Disagreeable 
temperature and sweating, all symptoms that are presumably due se( iuelae fo1 " 
to a ferment intoxication. Sometimes during the injection of fusion, 
blood the patient becomes cyanotic and dyspneic ; these are indi- 
cations to stop the infusion of blood. 

The results obtained from this practice are exceeding vari- Results 
able; some patients improve immensely at once, in others no 
effect whatsoever is observed, and in still others the disagree- 
able consequences enumerated above make their appearance. A 
few deaths have been known to follow transfusion. The method 
nevertheless should, at all events, always be given a trial, espe- 
cially when the cases are in so desperate a position that any 
measure, however dangerous it may be, becomes justifiable. 

Next in importance to the transfusion of blood is the trins- Transfusion 
fusion of normal salt solution, containing about 0.8 per cent of of normal salt 
sodium chloride to a litre of water; or this salt solution car? be 



76 



SIMPLE ANEMIA 



Hypodermo- 
clysis 



Treatment 
during* remis- 
sions 



Symptomatic 
treatment 



injected under the skin as follows:. The sterile solution is poured 
into a fountain syringe that is elevated about two or three 
feet above the bed; the fountain syringe is connected with a 
rubber tube that branches out into two ends each connected with 
a hollow needle ; the two needles are inserted either into the skin 
of the thigh or of the abdomen or into the pectoral fascia under- 
neath the breasts. From one to two litres of the solution may be 
injected in the course of from ten to fifteen minutes, care being 
taken that the region into which the fluid is injected is mas- 
saged during all the time the solution is flowing; this greatly 
facilitates the absorption of the salt solution. This method is 
quite painful and occasionally requires chloroform narcosis. The 
results obtained from saline solution are not so favorable by far 
as those obtained from the transfusion of normal human blood. 

During the periods of remission the patients should continue 
the use of small doses of arsenic. They should live on a nourish- 
ing diet similar to the one described above, and should preferably 
seek a resort with a moderately temperate climate, with the max- 
imum of sunshine and clear days, where they can lead an out- 
of-door existence, preferably at a moderate altitude, not exceed- 
ing three thousand feet. 

Sooner or later in the disease the condition will become aggra- 
vated again, provided the anemia is not due to intestinal para- 
sites. As soon as the condition of the blood becomes bad and the 
patients grow weak again, they should at once be put to bed and 
energetic treatment immediately instituted. 

Symptomatic treatment is synonymous with the treatment 
of the organs whose function becomes deranged ; thus the gastro- 
intestinal, the cerebral symptoms, the symptoms about the heart, 
the hemorrhages, should be treated as described in other sections. 



Indications 
for treating 
simple 
anemia 



SIMPLE ANEMIA. 

Simple anemia is always a symptom of some underlying dis- 
order, hence the treatment, broadly speaking, is synonymous 
with the treatment of the cause that produces the impoverish- 
ment of the blood. Every effort, therefore, should be bestowed 
upon finding this cause and removing it. Occasionally, however, 
simple anemia persists even when the underlying cause is re- 
moved, as, for instance, the anemia developing after internal or 
external hemorrhages, profuse vomiting, pregnancy, intoxication 
by intestinal parasites and various infectious diseases. In all 
of these cases the resulting anemia would, in all probability, 
heal spontaneously in time, but nevertheless it often becomes 



SIMPLE ANEMIA 77 

necessary to aid Nature in. its reparative endeavors as other- 
wise serious nutritional disorders would develop in different 
organs. 

Again, the disease which produces the anemia may be very 
chronic in character, so that while the cause of the anemia is 
known it may be difficult or impossible to remove it. This applies 
particularly to the simple anemia seen in tuberculosis, in chronic 
suppurative processes, after prolonged lactation, in malnutrition 
due to stenosis of the esophagus or organic diseases of the stom- 
ach, in nephritis, syphilis, chronic malaria and in various forms 
of chronic, poisoning. Here the anemia attains almost the dignity 
of an independent affection and urgently calls for special treat- 
ment. It is well to realize that in anemia due to chronic dis- 
orders of an irremediable character it is usually impossible to 
completely restore altogether normal conditions in the blood. 
Very much, however, can be done in this direction and no effort 
should, therefore, be spared to attain the best possible conditions. 

In the treatment of anemia the regulation of the diet is a very Diet 
important element. It is clear that every effort should be ad- 
vanced to maintain nutritive equilibrium, that is, to supply an 
amount of food sufficient to enable the organism to put forward 
its best efforts towards producing the regeneration of the blood. 
This can never be accomplished if the patient is chronically 
underfed. Unfortunately, in simple anemia the gastro-intestinal 
function is frequently perverted. This must be attributed to the 
malnutrition (resulting from an inadequate blood supply) of 
the gastric and intestinal glands and of the nerves supplying 
them. For this reason it is a matter of great importance in ar- 
ranging a dietary for an anemic case to carefully study the con- 
dition of the gastric function by means of test-meals and accord- 
ing to methods described in the Chapter of Diseases of the Stom- 
ach. The diet should then be accommodated exactly to the func- 
tional powers of the stomach and intestine. 

Broadly speaking, the diet should contain an abundance of Much albumen 
albuminous food. In cases of hyperchlorhydria this regulation 
is, of course, very easy to carry out. If there is a lack £>f hydro- 
chloric acid, then the latter must be supplied if an albuminous 
diet is administered. Meats of all kinds, preferably raw or rare, 
fish, game, eggs, milk are all very useful articles of diet. In 
addition there should be plenty of fresh fruits and vegetables. 
Whether or not it is of advantage to give foods that contain rela- 
tively large quantities of iron is doubtful, because the amounts 
of iron contained in these foods can be more readily supplied 
medicinally; nevertheless, yolk of egg, spinach, apples and all 
articles that contain relatively large amounts of iron may with- 



78 



SIMPLE ANEMIA 



Lack of appe 
tite 



out harm be liberally supplied. Carbohydrate foods, that is, 
cereals, bread, rice, potato, sweets should be given sparingly and 
fats should be given in moderation. 

If the anemia is primarily due to some gastro-intestinal dis- 
order, then exceptional care must, of course, be exercised in 
selecting a diet. This applies particularly to cases of anemia 
developing upon the basis of gastric or intestinal hemorrhage 
from ulcer. Here it may become necessary to put the stomach 
completely at rest for a time and to feed the patient exclusively 
Bectal feeding by rectum. The technique of rectal feeding is fully described 
under Stomach Diseases. 

Proper feeding in anemia is often rendered difficult because, 
many patients with simple anemia suffer from lack of appetite. 
This element can usually be corrected by the use of bitter tonics, 
as tincture of cinchona, in doses of one to two drachms; tincture 
of nux vomica, five to twenty drops; compound tincture of 
cardamom, one to two drachms; or orexin, in five grain doses. 
Very often anemic patients are benefited by drinking on rising, 
and fifteen to twenty minutes before each meal, a glass of hot 
water containing one-third of a teaspoonful of bicarbonate of 
soda. 

In severe cases of anemia rest, bodily, mental and psychic, is 
of the greatest importance. In the anemia following severe hem- 
orrhage, either internal <xr external, rest in bed is absolutely 
essential. Here the limbs should be elevated and the head placed 
low so that blood, at all events, will reach the brain and the vital 
centres in the medulla. After the bleeding has been stopped, it 
often becomes necessary in patients who are very much exsan- 
guinated to perform transfusion of normal salt solution, as de- 
scribed on page 74. If the facilities for transfusion are not 
immediately available, then what may be called auto-transfusion 
should be practised. This consists in wrapping bandages around 
the extremities, beginning at the distal end and wrapping towards 
the center. These bandages can be left in place for one or two 
hours. In this way enough blood is forced to the head, the 
medulla and the heart to sustain life; at the same time the 
patient should receive large amounts of water by rectum and, if 
he is conscious, by mouth. If collapse or heart failure threaten, 
then enemata containing alcohol (about two tablespoonfuls to 
the quart), or subcutaneous injections of ether or camphorated 
oil or of a 10 per cent, solution of camphor in ether, should be 
given. If necessary transfusion may be practised several times. 

Cases of chronic anemia are very susceptible to temperature 
changes. This is due to the deficiency of hemoglobin in the 
blood, to the reduction of oxidative processes and hence impaired 



Rest 



Management 
after hem- 
orrhages 



SIMPLE ANEMIA 79 

manufacture of heat and to the instability of the vaso-motor 
•centers. Consequently anemic cases are particularly liable to 
-catch cold, so that great care should be exercised in selecting 
sufficiently warm clothing and the proper foot-wear. Inasmuch Clothing and 
as the loss of heat from the surfaces of the body is best pre- 
vented by creating an immovable layer of air between the skin 
and the first garment, a material should be selected that is a 
poor conductor of heat, that rapidly absorbs perspiration from 
the surface of the body and permits slow evaporation of the 
absorbed moisture. The ideal material is wool, for the fine hairs 
that are contained in wool garments effectively keep the clothing 
at some distance from the skin, while, at the same time, the rough 
character of the wool produces some irritation and friction of the 
skin and hence a slightly hyperemic condition which is grateful 
to anemic patients. The roughness of wool garments stimulates 
perspiration, but the porous character of wool causes rapid ab- 
sorption of the moisture exuded from the sweat glands, while, at 
the same time, the sweat evaporates very slowly from the outer 
surface of the material; hence wool garments do not become 
saturated with moisture nor do they cling to the skin, so that 
they adequately protect the organism against loss of heat. Iu 
summer flannel and silk are less irritating to the skin and, at the 
same time, serve a useful purpose as bad conductors of heat. 
Linen and cotton underwear should never be worn by anemic 
patients (see also page 166). The foot-wear should be thick and 
the patient should wear woolen stockings during winter. 

On account of the susceptibility of anemic patients to tern- Bathing 
perature changes and particularly to cold, cold bathing should 
be absolutely forbidden. Even in neurasthenic and hysterical 
cases the use of cold or cool hydro-therapeutic measures that are 
otherwise so useful should be interdicted. Sea bathing is also 
absolutely detrimental to these cases. Hot baths, however, are 
very grateful and exercise a distinctly stimulating effect upon 
the metabolism, upon the circulation and upon the regeneration 
of the blood ; they should therefore be advised. 

If anemic patients are to select a climate or a resort they climate and 
should be sent to a moderate altitude, for a low barometric altitude 
pressure stimulates blood regeneration. That the climate should 
be warm and that there should only be slight temperature 

changes is self-evident. „ ,. 

Medicamen- 

The drug treatment of simple anemia consists chiefly in the tous treatment 

use of iron and arsenic. There are, however, frequently very Iro ? and ar ~ 

distinct contra-indications to the use of both these remedies ; thus Contra-indica- 

neither iron nor arsenic should ever be given if there are severe tions fo . r the 

gastro-intestinal disorders, because both of these drugs, without and arsenic 



80 



SIMPLE ANEMIA 



Rectal and 
hypodermic 
administra- 
tion 



Method of ad- 
ministering 
arsenic 



Method of ad- 
ministering 



question, have a tendency to irritate the stomach and the intes- 
tine. Nor should iron be administered to cases of anemia suffer- 
ing from pulmonary tuberculosis. I believe that it occasionally 
aggravates the condition of these patients and even stimulates 
a latent or quiescent tuberculous focus in the lungs to renewed 
dangerous activity. It also occasionally seems to produce a rise 
of temperature. Trousseau claims to have seen pulmonary hem- 
orrhage develop after the administration of iron in pulmonary 
tuberculosis. This observation has repeatedly been corroborated. 
I have never, personally, been able to convince myself of its 
truth. Arsenic is contra-indicated also in cases suffering from 
nephritis, for when the kidneys are diseased they eliminate the 
drug with difficulty and there is always danger both of irri- 
tating the diseased renal epithelia and of producing a cumula- 
tive arsenic effect. 

Gastro-intestinal disorders, therefore, should always first be 
treated and, if possible, cured, before iron or arsenic are given 
by mouth. In the meantime, both remedies may be administered 
by rectum, the iron in the form of dried blood or of reduced 
iron, or of tincture of the chloride of iron; arsenic preferably 
in the form of Fowler's solution. Arsenic may also be admin- 
istered hypodermically in the form of the cacodylate of soda (see 
page 74). 

In administering arsenic, the peculiarities and idiosyncrasies 
of the case must be carefully considered and the tolerance of 
each individual patient for the drug first carefully established. 
It is best, therefore, always to begin with small doses of arsenic 
and gradually to increase the quantity until the limit of toler- 
ance is reached; to keep the patient for several weeks upon a 
quantity of arsenic slightly below this dose; and then to grad- 
ually reduce the dose again. For the details of the administra- 
tion of arsenic, see Pernicious Anemia (page 73). 

In administering iron it is important to remember that the 
patient should receive about 0.01 gm. of iron per day. The exact 
preparation of iron used is immaterial. Personalty, I prefer 
reduced iron or the tincture of the chloride of iron to any of the 
organic preparations, for by employing simple inorganic prod- 
ucts the dose can be much more accurately gauged. Iron and 
arsenic waters can also be employed in the treatment of simple 
anemia (see page 74). 

It is best, in all cases of simple anemia, even after normal 
conditions in the blood have been re-established, to continue the 
use of small doses of arsenic and iron, that is, e. g., three to ten 
drops of Fowler 's solution and two to six grains of reduced iron 
a day, for several months. 



CHLOROSIS 81 



CHLOROSIS. 



The most characteristic feature of chlorosis is the reduction Definition 
of the hemoglobin in the individual red cells, combined with an 
increase of the blood plasma without any appreciable reduction 
in the specific gravity of the latter. The underlying taint seems 
to be more a perversion of lymph formation than of blood forma- 
tion. There is no anatomical evidence of disease of the blood- 
forming organs nor are there very marked quantitative changes 
about the red blood corpuscles or the leucocytes, nor generally 
any signs of degeneration of the latter. 

We are justified in assuming that in chlorosis the interchange 
of the fluids between the blood and the tissues is altered (wit- 
ness the great frequency of puffiness and edema), and this 
anomaly can best be explained by assuming a vaso-motor neuro- 
sis as the underlying cause. A strong neurosal element, more- The neurosal 
over, enters into the clinical picture of chlorosis, manifesting element 
itself not only about the vaso-motors of the body (remark the 
abnormal tendency to blushing and sudden pallor), but also in 
a variety of other manifestations that closely simulate the pic- 
ture of. hysteria. When we consider, finally, that the disease 
is most common in young girls during the period of adolesence, 
that it is frequently coupled with a variety of menstrual disor- 
ders, psychoses, perversions of the appetite, the sense of smell 
and taste and various secretory anomalies, we are justified in 
instituting causal treatment in chlorosis, more against the under- 
lying neurosis than against the condition of the blood alone. 
The causal and prophylactic treatment, therefore, should con- Causal treat- 
cern itself chiefly with improving the general and personal ment 
hygiene of the patients, in properly feeding them, and in com- 
bating, with all the means at our disposal, the psychic and neu- 
rotic elements that so often predominate in this disorder. 

The symptomatic treatment should be directed towards cor- Symptomatic 
recting the abnormal condition of the blood, and. by implication, treatment 
towards relieving symptoms in various organs attributable to 
functional disturbances that are superinduced largely by the 
malnutrition either of the organs themselves or of the nerves 
supplying them. 

One of the most important elements in the treatment of Rest 
chlorosis is rest. The patients should be put to bed and kept 
there for several weeks at a time. If possible, they should be 
removed from their home surroundings and treated either in an 
institution or in some resort where they can enjoy a change of 
scene and can carefully follow the directions of the physician 



82 



CHLOROSIS 



Gastric dis- 
orders 



during the period of convalescence. Kemoval from home alone, 
combined with rest, often effects a cure. 

Hydrotherapy Combined with rest in bed certain hydriatic measures are 

of great use. Best of all are wet packs administered by wrap- 
ping the patient every morning in a linen sheet wrung out of 
warm water (90-96° F.) and allowing them to lie in this 
compress, covered with woolen blankets, for about half an hour. 

Massage Mild massage of the extremities and the abdomen is also ex- 

ceedingly useful, both on account of its soothing effect on the 
nervous system and on account of its tendency to improve the 
circulation of lymph and hence promote the absorption of 
edemas. 

Diet In many cases of chlorosis there are secretory disorders of 

the stomach and not uncommonly muscular atony; thus gas- 
troptosis, from relaxation of the abdominal muscles, is frequently 
combined with dilatation of the stomach from atony of the gas- 
tric walls. Stomach disorders are so common that some authori- 
ties have attributed the syndrome of chlorosis to the digestive 
perversions. It is more probable, however, that the stomach dis- 
order is either a part symptom of the general neurosis, or is 
directly attributable to the malnutrition of the gastric walls and 
the gastric glands, that results from the deficiency of hemoglobin 
in the blood. In each case of chlorosis a careful analysis of the 
stomach contents should be repeatedly made and the diet ar- 
ranged accordingly, as outlined in the Chapter on Diseases of the 
Stomach. 

Abnormal It is due to the variable character of the secretory perversion 

cravings £ ^e stomach also that chlorotic girls so frequently develop ab- 

normal cravings; some seem to crave acids, others enjoy eating 
chalk, and it does not appear improbable that this is Nature's 
method of attempting to neutralize the lack of hydrochloric acid 
on the one side, or to counteract hyperchlorhydria on the other. 
Unless there is marked hypersecretion or hyperchlorhydria call- 
ing for a proteid diet and antacid medication, chlorotic patients 
do best on a diet consisting largely of vegetables and contain- 
ing the minimum of meat. 

Constipation This regime is particularly useful because in most cases there 

is also atony of the intestinal walls with very obstinate con- 
stipation. This frequent occurrence of constipation has led to 
the theory that chlorosis is due to stasis of bowel contents and 
abnormal putrefaction in the intestine, in other words, that it 
is an auto-intoxication from intestinal poisoning. Here, again, 
it seems more probable that the constipation is the result, and 
not the cause, of the chlorosis, for many cases develop without 



CHLOROSIS 83 

bowel symptoms, and constipation is more frequently secondary 
to the chlorosis than vice versa. 

The exact selection of the diet must therefore depend 
largely upon the shifting peculiarities of each individual case. 
Broadly speaking it should be nutritious and easily digestible, 
it should meet the state of the gastric and intestinal function 
and should above all take into consideration personal idiosyn- 
crasies of the patient; for lack of appetite is one of the most 
distressing complications of the disease. One should never 
force a chlorotic to eat food that is distasteful, nor should one 
generally forbid indulgence in articles that the patients crave 
but that are otherwise harmless. If this liberal plan is adopted, 
co-operation on the part of the patient is always most readily 
secured. 

The medicamentous treatment of chlorosis calls chiefly for Medicamen- 
iron, but this remedy can in no way be considered a specific for tous * r eat- 
the disease, although it has frequently been so considered; for 
many cases of chlorosis get well without iron, provided the gen- Iron 
eral treatment outlined above is carefully carried out; and, on 
the other hand, many cases of chlorosis fail altogether to re- 
spond to iron treatment alone. Iron, nevertheless, is by far the 
best remedy we possess in the treatment of chlorosis, and as it 
never does any harm it should be given in every case. 

The mode of action of iron in chlorosis is very difficult to Mode of action 
understand. Some of the iron is undoubtedly absorbed into the 
blood, but most of it is wasted in the stools; of the assimilated 
iron a part is built up into hemoglobin, a part stowed in the 
liver and spleen. One can hardly say that in chlorosis there 
is a deficit of available iron in the food and that the adminis- 
tration of iron by mouth supplies this deficit. The iron must 
rather be considered as a stimulant to the blood-forming organs. 
Bunge has advanced the theory that iron acts by combining with Theories in re- 
the sulphureted hydrogen that is generated by the putrefaction 8>ar . d to *^ e 
of albumens in the bowel, forming insoluble iron sulphid, and in chlorosis 
in this way protecting the organic iron compounds of the food 
and rendering them available; but there is little tangible evi- 
dence to show that this theory is correct; for, otherwise, any 
of the heavy metals that can combine with sulphureted hydrogen 
to form heavy sulphids should fulfill the same purpose, and 
this is not the case. Still others imagine that the iron, owing 
to its astringent properties, stimulates the gastro-intestinal 
mucosa to increased activity and hence improves nutrition. Im- 
material what the theoretical indications for the use of iron 
preparations in chlorosis may be, the empiric fact remains that 
it is, in most cases, the sovereign remedy that can improve not 



84 



CHLOROSIS 



Choice of iron 
preparations 



Organic and 
inorganic 
compounds of 
iron 



Blaud's pill 



Perchloride 
of iron 



Reduced iron 



Pill of aloes 
and iron 



Citrate of iron 
and quinine 



only the condition of the blood, but also all the other disagreeable 
phenomena that complicate the disease picture of chlorosis. 

It is difficult to decide whether so-called organic or inorganic 
preparations of iron are more useful. Personally, I have 
never seen any reason to use other than the ordinary inorganic 
preparations, for there is no evidence to show that the numerous 
organic preparations of iron are either more rapidly absorbed 
or less irritating to the gastro-intestinal tract, or clinically more 
effective than the inorganic preparations. As a matter of fact, 
any iron preparation is converted in the stomach into the chlo- 
ride; this usually combines with albuminous material to form 
an albuminate of iron, which, passing into the duodenum, is in 
part, as shown above, absorbed and deposited in the spleen 
and liver for future use, while the bulk is eliminated in the 
stools. 

The best iron preparation of all is Blaud's Pill, containing 
sulphate of iron and the carbonate of potash. This pill acts 
beneficially, first, on account of the iron carbonate it incorpor- 
ates, second, presumably, on account of the potassium it con- 
tains, for the latter is an important constituent of the red blood 
cells, and, finally, on account of its content of sulphuric acid 
which readily combines with toxic aromatic products derived 
from putrefactive processes in the bowel, converting them into 
non-toxic aromatic sulphates (indican and its congeners). The 
tragacanth, finally, that these pills incorporate possesses 
some laxative property which is useful. One to four pills 
may be given two or three times a day, preferably after eating. 
It is usually best to begin with small doses, say one pill three 
times a day, and then to gradually increase the dost until four 
or five pills are taken three times a day. 

Another excellent iron preparation is the tincture of the 
perchloride of iron, which may be given in doses of from five to 
fifteen drops three times a day. This medicine should always be 
taken through a tube in order to protect the teeth. Reduced 
iron, in doses of one to five grains (0.05 to 0.3 gm.) in capsule, 
is also a very useful inorganic preparation. 

It is impossible to enumerate all the other preparations of 
iron that might be used. The three named above usually ful- 
fill all the requirements. The Pill of Aloes and Iron may be 
mentioned, because it is particularly useful in chlorosis com- 
plicated with constipation. This pill contains sulphate of iron, 
the proper dose being four to eight grains three times a day. 
Another valuable official preparation is the Citrate of Iron and 
Quinine, containing ll^ per cent, of quinine and 14J<£ per cent, 
of iron, and given in doses of five to ten grains two or three times 



CHLOROSIS 85 

a day. The quinine in this pill is useful especially in cases that 
are characterized by great nervous asthenia, for the quinine un- 
doubtedly acts as a cerebral tonic. 

Among the organic preparations the following may be enu- Organic prep- 
merated, although, as stated above, none of them, in my opinion, ara 10ns 
possesses any advantage over the inorganic preparations, none 
is so reliable, so stable or so inexpensive. Ferratin, in doses of 
from eight to twenty grains (0.5 to 1.3 gm.) per diem. Carni- Ferratin 

ferrin, containing 35 per cent, of iron and combined with sarcinic , T arni e J™ 
' r Hemoglobin 

acid, and given in doses of from five to ten grains (0.3 to 0.6 p e ptonates of 

gm.) three times a day. Hemoglobin itself may also be used. iron 
The various albuminates and peptonates of iron possess no par- 
ticular advantages. The administration of iron in combination 
with manganese is no more effective than the administration of Iron and man- 
iron alone, although extravagant claims have been made for this ^ anese 
therapy. 

There are certain contra-indications to the use of iron and Contra-indi- 
there is occasionally difficulty in administering it; thus in very U s e 10 of S iron * 
severe dyspeptic disorders, such as we not uncommonly see in 
chlorosis, iron occasionally aggravates the gastric symptoms. In 
such cases the dyspepsia should first be treated, as described 
in the Chapter on Diseases of the Stomach, and iron not given 
by mouth until the gastric symptoms are relieved; if need be 
iron may here be given by rectum, in the form of the tincture 
of iron in starch enema. Occasionally cases of chlorosis suffer 
from severe gastralgia, which is markedly aggravated by the ad- 
ministration of iron; in such cases the hyperesthesia of the 
stomach should be first treated by the use of hot applications 
to the epigastrium, a milk diet, small doses of cocaine, as de- 
scribed on page 19, or of silver nitrite (see index) ; or mem- 
thol, preferably combined with some alkali may be given in small 
doses (0.05 to 0.1 gm.) a day. 

The use of iron waters is occasionally beneficial, especially iron waters 
if the waters can be taken at the resort where the iron source 
is. The use of bottled iron waters, however, is, as a rule, use- 
less, because most natural iron waters contain the iron in solu- 
tion as a carbonate; when they are bottled the carbonic acid 
evaporates in great part and the iron precipitates out, so that 
the water itself contains practically no iron. This objection 
does not, however, apply to waters containing the sulphate or 
chloride of iron. 

Arsenic is less important in chlorosis than in other forms of Arsenic 
anemia. As it possesses a general tonic effect in small doses, its 
administration, however, can do no harm. It is best given in the 
form of Fowler's solution, beginning with small doses, e. g., 



86 



LEUKEMIA 



Dyspnea 
Palpitation 



Bleeding 



Sweating 



three to five drops in plenty of water three times a day and in- 
creasing the dose a drop a day until fifteen to twenty drops are 
being taken in the twenty-four hours ; and then the dose should 
gradually be reduced, and, if necessary, a second course of this 
kind instituted. The existence of dyspeptic symptoms, however, 
is a distinct contra-indication to the use of arsenic in chlorosis. 

Symptomatic treatment of the cardio-vascular signs is rarely 
necessary, because they improve under rest and iron. The 
dyspnea, therefore, and the palpitation (see page 65) that these 
patients complain of rarely calls for special treatment. 

A word of warning may be uttered in regard to the dangers 
of bleeding cases of chlorosis, a practice that has recently be- 
come popular again. The plethora is removed only for a short 
time by venesection; and in chlorosis especially, owing to the 
disturbed vaso-motor tone, a reactive outpouring of fluid' into 
the blood soon occurs, so that the purpose of the bleeding is 
immediately counteracted or even over-balanced and nothing is 
gained. The one possible benefit that could accrue from bleeding 
must be attributed to the profuse perspiration that usually fol- 
lows venesection in chlorosis; but this beneficial stimulation of 
the lymph flow, and the loss of fluid through the sweat glands, 
can be produced much more easily by hot baths or hot air. 
Sweating, therefore, is often useful in chlorosis for it promotes 
concentration of the blood and hence better nutrition because 
each unit volume of blood contains more hemoglobin. In chlo- 
rosis particular care, however, must be exercised to prevent cere- 
bral anemia from sweating by heat, so that this treatment should 
never be instituted with the patient sitting up, and cold appli- 
cations should always be made to the head while the patient is 
being sweated. 



Leukemia and 
pernicious 



Leukanemia 

Causal treat- 
ment 



II. LEUKEMIA. 

Although the blood picture of leukemia differs altogether 
from that of pernicious anemia, the two classes of blood disorder, 
nevertheless, must be considered as pathogenetically related; 
for in both instances we have some noxious agency, presumably 
toxic in character, affecting the blood-forming organs and chiefly 
the bone-marrow. Occasionally individual cases are seen in 
which both the red and the white cells are simultaneously affect- 
ed, so that a disease is produced that occupies an intermediary 
position on the border line between pernicous anemia and leuke- 
mia. This has been called leukanemia (Leube). 

The causal treatment of leukemia is therefore the same as 
that of pernicious anemia, in both cases unfortunately equally 



LEUKEMIA 87 

unsatisfactory, because iu neither case do we know where to 
concentrate our attack. In leukemia, in fact, we know even 
less what indicatio causalis to meet than in pernicious anemia. 
Nevertheless, every effort should be put forward to look for a 
possible cause and particular attention should be bestowed above 
all upon bowel antisepsis and the removal of intestinal parasites. 
Free evacuation of the bowel contents, and treatment directed 
towards any systemic disorder (syphilis) that may be present 
and that might even remotely be accused of causing the leukemic 
blood picture, should be energetically instituted. 

The treatment, causal and symptomatic, of the different Splenic, 
forms of leukemia is the same. The old pathogenetic differ- iymphatic 
ences between splenic, lymphatic and myelogenous leukemia that leukemia 
have been formulated have only an anatomic interest and can 
no longer be recognized as useful for clinical differentiation. The 
preponderance, in individual cases, of lymphatic or of splenic 
swellings is nowadays considered to be of subordinate import- 
ance; for hyperplasia of the spleen or lymph glands, or of Both, 
occurs both with and without lymphocytosis (pseudo-leukemia, 
see next chapter). On the other hand, leukemia may occur 
with myeloid degeneration of the bone-marrow and no splenic 
or lymphatic swellings. We can conclude from this that in 
leukemia, as well as in pernicious anemia, the inflammation of 
the bone-marrow is after all the most important and presumably 
the determining factor. For clinical purposes it is simpler and 
more exact therefore merely to speak of a lymphocytic and a 
leucocytic leukemia, indicating in this way that in the former Lymphocytic 
case the lymphocytes predominate in the blood, in the latter the f^e^a 007 * 10 
leucocytes, i. e., neutrophile, eosinophile, polynuclear and mast 
cells. 

Leukemia, as far as we know, is presumably never cured, 
but life can be prolonged, and long remissions with improve- Limitations of 
ment of the blood picture and great symptomatic relief can be ^u^emia* m 
brought about, by judicious treatment. The use of remedies in 
leukemia should be carefully instituted. "Whenever any drug 
is given the effect should always be carefully watched, for 
leukemic patients, possibly owing to the perversions of their 
leucocytic (antitoxic) function seem to be particularly suscep- 
tible to drug intoxications; moreover, they frequently suffer Care in giving 
from dyspepsia and diarrhea, all elements that render them espe- J^mic patients 
cially liable to drug poisoning and that should be included in 
the calculation both in prescribing drugs and in ordering the diet. 

The remedy that seems of the greatest value in leukemia is Arsenic 
arsenic. It should be given as in pernicious anemia (see page 
73). Provided the gastric functions are normal it may, how- 



LEUKEMIA 



Dose and ad- 
ministration 



Sodium arsen- 

iate 

Sodium caco- 

dylate 

Injection of 

arsenic 



Quinine 

Phosphorus 

Iodine 



Extracts of 
spleen 

Lymph glands 
Bone marrow 



Oxygen 



ever, with care be given in somewhat larger doses at first in 
leukemia than in anemia. It is usually safe to begin with three 
times fifteen drops of Fowler's solution a day during the first 
week, giving three times twenty drops during the second week, 
three times twenty-five drops during the third week and, if no 
toxic symptoms appear, three times thirty drops during the 
fourth week. This dose should be continued for some time until 
favorable changes appear in the blood picture, and it may then 
be gradually reduced by stages. Several courses of arsenic 
should be given. It is occasionally good practice to change the 
preparation of arsenic and to alternate with the use of Fowler's 
solution, sodium arseniate and sodium cacodylate (see page 74). 

The injection of arsenic into the lymph glands or into the 
spleen is to be condemned in leukemia (see also page 89). The 
effects produced by this treatment have never been favorable 
and, per contra, much damage has been done. (Subcutaneous 
inflammation and necrosis; infarction and other mechanical 
injury to the lymph glands and to the spleen; rupture of the 
spleen; severe hemorrhages; have all been reported.) 

Quinine has also been recommended very warmly in the 
treatment of leukemia. It may be given as the muriate of 
quinine, in doses of five to fifteen grains (0.3 to 1.0 gm.) three 
times a day, preferably in combination with arsenic or iron. 
Phosphorus, too, is occasionally of value in leukemia. A very 
useful prescription is the syrup of iron phosphate with quinine 
and strychnia. It may be given in half or teaspoonful doses, 
three or four times a day. Iodine and the iodides are no longer 
used in leukemia although at one time they were considered to 
be efficacious. 

Extract of spleen, lymph glands and bone-marrow are ex- 
tensively used in leukemia. I have never been able to convince 
myself of their efficacy; nevertheless, there can be no harm in 
employing them, as some reliable authorities claim to have seen 
benefits accruing from their administration. All conclusions, 
however, in regard to the efficacy of these, or, for that matter, of 
any other remedy in leukemia must be very conservatively inter- 
preted, because the disease has a natural tendency to sponta- 
neous remissions. 

The inhalation of oxygen occasionally affords symptomatic 
relief, especially in cases with severe dyspnea and cardiac weak- 
ness. At least 100 to 150 litres of the gas should be given during 
twenty-four hours, if any good effects are to be expected. 

The fact that leukemia occasionally seems to improve if the 
subjects develop some intercurrent infectious disease, chiefly 
erysipelas and tuberculosis, has been utilized therapeutically. 



PSEUDO-LEUKEMIA 89 

Tuberculin and erysipelas antitoxin have been injected in some Tuberculin 
cases with good temporary results. This method, however, is Erysipelas 
exceedingly precarious, and until further reliable data in re- 
gard to its efficiency shall be forthcoming it is best to suspend 
judgment in regard to its use. 

Local treatment is to be absolutely condemned. At one 
time it was fashionable to inject arsenic or ergot into the lymph Injections of 
glands or the spleen, to perform galvano-puncture or even to wniph. glands 
practise extirpation of large lymph glands or of the spleen. Galvano- 
Lymph gland excision has never produced any good results in P uncture < 
leukemia. The practice, moreover, is irrational, because, as 
stated above, the primary affection must not be sought for in 
the lymph glands, but rather in the bone-marrow. All the cases 
in which the spleen was excised died very shortly, probably 
sooner than they would have died without splenectomy, so that Splenectomy 
even this operation, however useful it may appear for the pur- 
pose of relieving great intro-abdominal pressure when the spleen 
obtains enormous dimensions, must be considered unjustifiable. 

The diet in leukemia should take into consideration the state Diet 
of the digestive apparatus, but, broadly speaking, should be 
abundant and highly nutritious, and should consist largely of 
nitrogenous material ; and every effort should be put forward 
to maintain adequate nutrition, in order that the patient may 
possess the greatest resisting powers to combat the inroads of the 
disease. 

Symptomatic treatment of the dyspepsias, of the hemorrhages, Symptomatic 
of cardiac weakness, are spoken of in the Sections on Diseases complications 
of the Stomach and Intestine, the Hemorrhagic Diathesis and 
Diseases of the Heart. 

For the profuse sweats that frequently torture leukemic pa- Treatment of 
tients alum applied to the surfaces of the body in one per cent, ^^j^f in 
solution; or camphoric acid, given by mouth, in closes of from 
fifteen to thirty grains (1 to 2 gm.) in capsule, or atropin one- 
•two-hundred-and-nftieth grain {% mg.) repeated, by mouth and 
hypodermically ; or the extract of belladonna, in quarter to one 
grain doses, or finally, agaricine, in doses of one-twelfth to one 
grain (5 to 60 mg.) in pills, repeated, may be used. 



III. PSEUDO-LEUKEMIA. 

The prefix "pseudo" placed before the name of a disease is Nomenclature 
intended to designate a special syndrome that differs from the and definition 
disease it simulates; pseudo means false. There cannot, how- 
ever, be a false leukemia but there can be a false name, and 
■pseudo-leukemia is in fact merely a designation for a variety of 



90 



PSEUDO-LEUKEMIA 



Hodgkin's 
disease 

Splenic 
anemia 

Banti's 
disease 
Pseudo-leu- 
kemia 
Spleno-lym- 
phatica 



Recurrent 

glandular 

fever 

Tuberculous 

adenitis 

Scrofula 

Sarcomatosis 

of lymph 

glands 



Etiology 



Causal and 
prophylactic 
treatment im- 
possible 

Symptomatic 
treatment 



diseases that resemble leukemia in some of their manifestations 
but are not leukemia. 

Inasmuch as in leukemia swelling of the lymph glands and 
the spleen is common, many different disorders that lead to 
lymphatic and splenic enlargements without the characteristic 
blood picture of leukemia, have been grouped under the name of 
pseudo-leukemia. In some of these disorders the lymph swell- 
ings predominate; in others the splenic tumor. All show the 
blood picture of a simple anemia, occasionally also a lymphocy- 
tosis. Pseudo-leukemia rarely develops into true leukemia, then 
namely, as shown in the previous sections, when the bone- 
marrow becomes involved in the disease process. 

If the lymph swellings predominate we speak of pseudo- 
leukemia lymphatica (Hodgkin's disease) ; if the splenic tumor 
is particularly developed of pseudo-leukemia splenica, or splenic 
anemia; when it appears combined with hepatic cirrhosis and 
simple anemia, of Banti's disease. In all cases both the spleen 
and the lymph glands are probably involved to some extent; if 
they are both equally involved we speak of pseudo-leukemia 
spleno-lymphatica. 

Again, the lymphatic swellings may be accompanied by a 
remittent or intermittent type of fever, then we have recurrent 
glandular fever; this form is presumably a tuberculous adenitis, 
and as a matter of fact many cases of multiple tuberculous lymph 
gland swellings, as well as scrofula, are often included under the 
head of pseudo-leukemia. The same applied to multiple sar- 
comatosis of the lymph glands, that often cannot during life 
be distinguished from simple lymphadenomata. 

It will be seen, therefore, that the term pseudo-leukemia 
covers a multitude of different clinical entities, many of them of 
unknown etiology. Some of the cases seem to develop on the 
basis of tuberculosis or malaria, others after diseases of the ton- 
sils and pharynx, after measles, whooping cough and especially 
influenza. Given an inherited or acquired syphilis, vulnera- 
bility of lymphoid tissue, then a variety of noxious agencies seem 
capable of producing general lymphadenitis and splenitis. What 
factors determine this disposition and what noxious agencies 
become operative to cause the swellings, whether they are infec- 
tious or toxic, endogenous or exogenous, we do not always know. 

It is clear, therefore, that effective causal treatment and 
prophylaxis of the various forms of pseudo-leukemia is, in the 
obscurity of our present knowledge, impossible. 

Symptomatic treatment is, however, often efficacious in re- 
ducing the glandular swellings and the splenic tumor, especially 
early in the disease, and in correcting the anemia that usually 



PSEUDO-LEUKEMIA 9l 

complicates this disorder. With, the reduction of the tumors 

most of the pressure symptoms produced by them promptly 

yield so that the latter rarely call for special treatment. 

The chief remedy, again, is arsenic, employed as described Arsenic 

under Leukemia, i. e., either in the form of Fowler's solution, 

or as arsenious acid, or in the form of the Asiatic pill (see page 

73). All these arsenic preparations, if given by mouth, should 

be administered after eating. In pseudo-leukemia sodium caco- 

dylate (sodium dimethyl arseniate) is also a useful remedy. 

It contains nearly two-thirds parts of arsenious acid and seems Sodlun * 

. J * cacodylate 

to be less irritating to the stomach than Fowler's solution or 

the ordinary arseniate of soda. It should be administered in 
pill form, each pill containing from one-sixth to one grain (0.01 
to 0.06 gm.). From one to six pills a day may be safely ad- 
ministered, or a watery solution may be employed in the strength 
of one to fifteen, from five to twenty-five drops a day being given 
of the latter. After the use of cacodylate of sodium the patients 
very soon develop a characteristic odor of garlic on the breath. 

Whereas, in leukemia, the sub-cutaneous or intra-parenchy- i n t ra -paren- 
matous administration of arsenic in any of its forms is to be con- chymatous in- 
demned as useless, irrational and dangerous, in pseudo-leukemia arsenic 
it occasionally acts beneficially. One may either give Fowler's 
solution or sodium arseniate. If Fowler's solution is used, Technique 
either for injection into lymph glands or into the muscle tissue, Fowler's solu- 
preferably of the gluteal and anterior abnominal region, it is best 10n 
to administer it diluted in the proportion of one to three with 
water to which one-half per cent, of carbolic acid is added as 
an antiseptic. Of this solution about V2 cc - should be in- 
jected at a time in the beginning, and the dose gradually in- 
creased later on if no untoward symptoms develop. Better than 
Fowler's solution for injection is sodium arseniate. This is Solution of 
prepared as follows: 1.0 gm. of arsenious acid is boiled with 5 sodium arsen- 
cc. of normal sodium hydrate solution until a clear solution is 
obtained, and 600 cc. of distilled water are then added. In 
using this solution for injection a Pravaz syringe is filled one- 
half with water and one-half with sodium arseniate solution 
and about 1 cc. of this mixture is injected into the enlarged 
lymph glands. Still another useful preparation for hypoder- 
mic use is a 10 per cent, solution of sodium cacodylate of which Sodium caco- 
half a Pravaz' syringe full is injected at a time. 

The indications for the use of quinine and phosphorus are Quinine-phos- 
the same as in leukemia. These remedies act as general tonics 
and occasionally do some good. Iodide of potash also has a Iodide of 
place in the treatment of pseudo-leukemia; it should be given 
in the form of the saturated solution, in gradually increasing 



92 



PSEUDO-LEUKEMIA 



Local appli- 
cations 
Sapo kalinus 

Iodoform 



doses. In general tuberculous adenitis I consider this drug 
dangerous; one should, therefore, always be quite sure of one's 
diagnosis before employing it. 

For local application the best remedy is green soap (sapo 
kalinus viridis) or sapo kalinus. Of this about a teaspoonful 
is daily rubbed into the skin over the affected glands. Occa- 
sionally the addition of iodoform to this soap is of use ; for the 
alkali in the soap loosens the epidermis and permits the free 
entrance of iodoform into the tissues surrounding the affected 
gland. A very good mixture is : 



i* 



Iodoform, 
Sapo kalinus, 
Vaselin, 
M. 



5 gm. 

aa 20 gm. 



Iron and ar- 
senic for the 

anemia 



Indications 
for gland ex- 
tirpation 



Treatment of 

splenic 

anemia 



In view of the simple anemia that is generally present, iron, 
as described in the part on The Anemias, is indicated. One can 
conveniently combine iron and arsenic by giving the cacodylate 
of iron, thus : 

Cacodylate of iron, 1.0 gm. 

Cinnamon water, 25. cc. 

M. S. Fifteen to fifty drops three times a 
day, after meals. 

In case all these medicinal measures, combined with 
proper feeding and ideal hygienic conditions, fail to cause the 
disappearance of the glandular swellings, and especially if cer- 
tain glands, by . mechanically compressing important nerve 
branches or blood vessels, produce disagreeable secondary 
symptoms, then extirpation of the glands becomes necessary. 
Some clinicians go so far as to claim that the excision of a few 
of the enlarged glands exercises a beneficial effect upon the 
whole disease process. Others, again, claim that excision per 
contra occasionally produces an aggravation of symptoms and 
accelerated growth of the remaining glands. For the purpose, 
therefore, of influencing the disease process, gland extirpation is 
probably a doubtful, possibly a precarious, procedure, and the 
only real indication for performing this operation is the relief 
of pressure symptoms. 

In cases of splenic anemia, i. e., pseudo-leukemia in which 
the spleen enlargement predominates over the lymphatic swell- 
ings, arsenic, iron and the other medicines recommended above 



X-RAY TREATMENT — PSEUDO-LEUKEMIA AND LEUKEMIA 93 

are also indicated. Injections of arsenic, however, into the 
spleen itself are always a dangerous procedure and have so far 
never produced results sufficiently favorable to warrant their 
recommendation. On the contrary, disagreeable and dangerous 
results have often followed this practice so that it is to be con- 
demned as useless and unwarranted. 

The application of green soap, or of any other remedies, over 
the splenic region, excepting as counter-irritants to relieve pain, 
is useless. Electrization of the spleen, which has also been rec- 
ommended, is altogether without effect. Cold continuously ap- Cold to the 
plied to the splenic region occasionally produces at least symp- sp een 
tomatic relief and has been known to reduce the splenic swell- 
ings. The ice bag intermittently applied is probably the best 
and simplest method of producing this result. 

A variety of remedies have, at different times, been recom- Q umme 
mended for reducing the splenic tumor, chief among them being uca yp u 
quiniue and eucalyptus. These remedies, however, presumably 
exercise their good effect only in cases of large malarial spleen, 
and they should therefore only be used if the existence of malaria 
can be determined by examination of the blood; otherwise they 
are useless. 

Excision of the spleen has been frequently performed, and Splenectomy 
in some cases this operation has been followed by very favorable 
results, especially if splenectomy was performed relatively early 
in the disease. The main indications for splenectomy in ad- 
vanced cases are pressure symptoms due to the often enormously 
enlarged organ; if many lymph glands are involved at the same 
time the results are far less favorable. The operation, of course, 
is not without dangers, especially if adhesions have formed in 
the region of the spleen. The existence of a cirrhosis of the liver 
is always a contra-indication to splenectomy; consequently in 
Banti's disease this operation should not be performed. 



THE X-RAY TREATMENT OF PSEUDO-LEUKEMIA AND LEUKEMIA. 

(Dr. W. A. Pusey, Chicago.) 
In pseudo-leukemia the glands may be made to disappear un- p seu a _i eu . 
der X-rays. This happens not only with superficial glands, but kemia 
it also happens with glands in the pelvis and in the mediastinum. 
Where there is cachexia this gradually disappears as a rule 
pari passu with the disappearance of the glands. The improve- 
ment is prolonged, but recurrences are apt to take place. Of the 
first two cases treated with X-rays, one has had two serious re- 
currences in this time, but these have promptly yielded to X-rays, 



94 X-RAY TREATMENT — PSEUDO-LEUKEMIA AND LEUKEMIA 



Leukemia 



Spleno-megaly 



and he has been able to pursue an arduous occupation with the 
loss of not more than two months' time in the last four years. 
The other case had a recurrence within a few months, for which 
an operation was performed, and he died of aspiration pneu- 
monia. 

Most of the cases of leukemia treated were spleno-myelogen- 
ous; a few were lymphatic. The results in both types have been 
about the same. The effect on the glands, including the spleen, 
is practically the same as in pseudo-leukemia. In numerous 
cases spleens filling a large part of the abdominal cavity have 
diminished until they were hardly palpable. In other cases, 
however, the diminution in the spleen while marked was not so 
great. The changes in the lymphatics may or may not be accom- 
panied by corresponding improvement in the blood. As a rule 
the blood rapidly improves, and may return to normal in its 
cellular composition. The cells which are slowest to disappear 
are the myelocytes; in some cases their percentage will remain 
high even after the blood otherwise has become normal. In most 
cases the improvement in the cachexia is more rapid than the 
improvement in the condition of the blood, and in many cases, 
in which the changes in the blood was relatively slight, the im- 
provement in physical vigor has been great. 

The persistence of the results in leukemia is not as long as in 
pseudo-leukemia. The disease may be expected to recur, but in 
many instances the relapses may be treated successfully. There 
are on record at the present time several cases which, with 
periods of treatment at intervals of a few months, have remained 
in a fair state of health for two or three years. 

I have treated one case of spleno-megaly without blood 
changes other than anemia, In this case the spleen extended 
from the brim of the pelvis to the diaphragm, and a hand's 
breadth to the right of the umbilicus. This spleen diminished 
with great rapidity so that within six weeks it was just palpable 
under the border of the ribs ; the patient 's general physical con- 
dition improved so greatly that he was able to resume his occu- 
pation and remained in good condition a year later and has, I 
believe, thus far had no relapse. 



THE HEMORRHAGIC DIATHESIS 95 

IV. THE HEMORRHAGIC DIATHESIS. 

There are a number of diseases of obscure origin that are ciassifi t' 
characterized by the occurrence of hemorrhages in various or- Scurvy 
gans. The chief representatives of this group are scurvy, hemo- Hemophilia 
philia, and purpura. This classification is more or less Purpura 
arbitrary and the three disorders are closely related 
and occasionally merge into one another. Hemophilia, 
in the overwhelming majority of cases is due to a 
transmitted hereditary taint and is a permanent con- 
dition, whereas scurvy and purpura rheumatica are acquired, the 
former often occurring endemically, usually as the result of mal- 
nutrition with severe general disturbances ; the latter always oc- 
curring sporadically, generally without severe systemic disturb- 
ances and rarely dependent upon definite external conditions. 
Even in scurvy and purpura, however, one is almost forced to 
the conclusion that a congenital predisposition to hemorrhages 
exists by the occasional appearance of scurvy or purpura in 
subjects who are healthy and in whom none of the predispos- 
ing or determining factors that are usually incriminated with 
producing these diseases are operative. The diseases grouped un- 
der the name of the hemorrhagic diathesis, especially, nowa- 
days, scurvy, are fortunately very rare, so that their treatment 
is relatively of subordinate importance and may hence be dis- 
cussed very briefly. 

SCURVY. 

A number of theories in regard to the causes of scurvy Causal treat' 
exist. There seems to be no doubt that food factors play an men 
important role in its production. The absence of potassium 
salts, the excessive ingestion of salted foods, the lack of suffi- 
cient vegetables and fruits, the lack of fat in the diet have all 
been accused of producing the disease. At all events, in the 
practical treatment of the disease fresh vegetables containing 
potassium salts, viz., chiefly potatoes, cabbage, spinach, water- Diet 
cress, carrots, turnips, onions, artichokes, asparagus, oranges, 
and in addition milk, fresh meat, containing the blood, and 
meat extracts should above all thing's be immediately supplied. 
As a rule a scorbutic patient if placed at rest and fed on a diet Rest 
of this character will recover without further medicamentous 
interference. 

As a prophylactic measure the use of lemon or orange juice Prophylaxis 
has been recommended, especially in children who are fed upon 
artificial foods lacking so-called anti-scorbutic elements, and 



96 



Hygiene 



lorseradish 



Aromatic 
tonics 



Yeast 



Treatment of 
the gums 



Surface hem- 
orrhages 



Styptics by 
mouth 



in individuals, like sailors or arctic explorers, who are forced 
to live for long periods of time npon a diet consisting largely 
of preserved foods. In the English navy, for instance, it is a 
compulsory rule that the sailors be given every day a lemonade- 
consisting of 14 gm. of lemon juice, 429 gm. of sugar and 112 
gm. of water, at dinner. 

The establishment of ideal hygienic conditions is also of 
great importance. There seems to be no doubt that lack of 
light and fresh air, exposure to cold and dampness and lack 
of proper exercise all contribute towards the outbreak of scurvy,, 
especially when many subjects are massed together in one dwell- 
ing for long periods of time. 

Of remedies that have been recommended herba cochleariae 
(Horseradish) was for a long time the most popular one. Aro- 
matic tonics, tannic acid, quinine and many other remedies have- 
been recommended, but it is generally unnecessary to give these 
medicines excepting to stimulate the appetite, or as general 
tonics. Yeast, too, is advised in doses of 200 to 300 gm. daily. 

Particular attention must be paid to the laceration of the- 
gums, for this is one of the most distressing symptoms of the 
disease. Here certain washes are necessary. Peroxide of hydro- 
gen may be applied directly to the gums, or a permanganate 
solution, 1 to 300, or a solution of silver nitrate, five grains to 
the ounce, or chlorate of potash solution, 1 to 50, or equal parts 
of the tincture of myrrh and catechu. In addition the teeth 
should be carefully looked after and mechanical irregularities 
corrected. For the gum hemorrhages adrenalin, in 1 to 1000 
solution, or cocaine (10 per cent solution), or iron perchloride 
(concentrated solution), or gelatine 10 pep cent [sterile) are 
probably the best remedies. 

The same local treatment may be used in surface hemor- 
rhages in other parts of the body. In bloody infiltration of 
muscles the application of a hot mixture of vinegar, one part, 
and water, two parts, is frequently very grateful. Occasion- 
ally ice applied to the bleeding area, or swallowed, in case of 
gastro-intestinal hemorrhage, is useful. The internal adminis- 
tration of styptic drugs like ergot, chloride of iron, etc., is useless. 
Occasionally pressure bandages or tamponade become neces- 
sary to stop hemorrhages. Surgical measures are always dan- 
gerous owing to the hemorrhagic tendency that exists. Great 
care should also be exercised in the use of drastic purges or 
other drugs that stimulate violent peristaltic movement, for 
bowel bleeding may occasionally be produced by their admin- 
istration. 



HEMOPHILIA 97 



HEMOPHILIA. 



In view of the hereditary character of this disease and the Prophylaxis 
transmission of the disorder through the females of the family, 
immaterial whether they be hemophilic themselves or not, mar- 
riage of the women of "bleeder" families should always be for- Marriage 
bidden. Male members who are not hemophilic, however, may 
marry. If it is known that at one time in the family history 
of a hemophilic man hemophilic children were born from a 
hemophilic father, then the male members of such a family 
likewise should be advised against marriage. 

Individual prophylaxis in all members of a bleeder family Individual 
is very important, especially during childhood and early adol- prop y axis 
esence. Thus all operative inroads, however slight they may be, 
should be avoided during childhood, as circumcision, the re- 
moval of moles, cutting of the frenum of the tongue, perforating Danger of 

the ears. Vaccination, however, seems to be without danger in minor oper- 

ations 
hemophilia, so that the children can be given the benefit of pro- 
tective inoculation against smallpox. 

The care of the teeth is, of course, of the greatest importance Care of the 
and even slight defects should be treated with the object in teetn 
view to prevent the necessity of tooth-extraction. Leeching, 
cupping and vesication should never be practised in children 
from hemophilic families. 

The toys that they are permitted to play with should be 
of such a character that the children cannot injure themselves. 
Violent gymnastic exercises, in fact, any pursuit that can lead 
even to slight surface abrasions or other bodily injury should 
be forbidden. In choosing a calling some occupation should 
be selected that does not necessitate contact with machinery or 
the use of sharp tools. 

The diet in hemophilia should consist largely of vegetables Diet 
and should be selected approximately on the same principles 
as the diet in scurvy (see page 95). Alcoholics, tea and coffee, 
condiments and spices should be reduced, in fact, nothing should 
be eaten that can irritate the cardio-vascular apparatus. 

A great number of remedies have been recommended for Medicamen- 
the cure of the hemophilic tendency, while but few of them have tous treatment 
vindicated the claims advanced for them by the different clini- 
cians who have advised their use. The laity have great faith 
in the use of large quantities of lemons or of other citrous Lemons 
fruits, and some clinicians report good results from the continued 
use of citrates. Mineral acids, too, deserve a trial, preferably Mineral acids 
sulphuric acid, either as acid sulph. dil, ten to thirty drops sev- 



98 



PURPURA 



Sulphates 



Ergot 

Lead acetate 

Hydrastis 

Opiates 

Treatment of 

hemorrhages 

by surgical 

means 



Subcutaneous 
injection of 
gelatine 



Calcium 
chloride 

Surface hem- 
orrhages and 
bleeding into 
cavities 



eral times a day, or as acid sulph. aromat., five to fifteen drops. 
Magnesium and sodium sulphate are also spoken of favorably, 
the latter remedies possibly acting beneficially from the sul- 
phuric acid they contain, and through their effect upon the 
bowels; that is, by promoting watery evacuation and hence pos- 
sibly greater concentration of the blood and also by counter- 
acting the absorption of bowel poisons. 

Ergot, lead acetate, hydrastis, opiates, have all been rec- 
ommended, but opinion seems to indicate that they are of no 
value in hemophilia. 

Hemorrhages, when they occur, must be treated chiefly me- 
chanically and according to surgical principles, i. e., the bleed- 
ing part must be elevated, compression applied above the bleed- 
ing area and occasionally a ligature placed about the afferent 
artery; thus a case of severe hemorrhage in a hemophilic fol- 
lowing the extraction of a tooth is reported in which the com- 
mon carotid had to be ligated before the bleeding stopped. 

The subcutaneous injection of gelatine may also be tried. A 
2 to 3 per cent, neutralized solution of sterile gelatine in physio- 
logical solution should be heated to body temperature and from 
5 to 200 cc. injected under the skin (technique, see Aneurism of 
the Aorta, page 58). This occasionally stops the bleeding. 
Calcium chloride, to judge from the case reports that have been 
published, is of no value. 

Surface hemorrhages should be treated as described 
under Scurvy. Joint hemorrhages and hemorrhages into 
the various serous cavities of the body (pericardium, pleura, 
peritoneal cavity) epistaxis, etc., call for special treatment, the 
details of which are described in their appropriate places. 



PURPURA. 

Nomenclature Various forms of purpura have been distinguished under 

the names of purpura simplex, purpura hemorrhagica, purpura 
rheumatica, syn. peliosis rheumatica or Schoenlein's disease, and 
Morbus Maeulosus of Werlhoff. All forms of purpura are closely 
related and the clinical differences are very artificially con- 
structed. At the bottom of all these disorders is a hemorrhagic 
diathesis, i. e., generally a pale, tender, vulnerable skin with 
a tendency to bleeding, and usually an anemic condition of the 
blood. Such individuals are particularly susceptible to tem- 
perature changes and hence to rheumatoid disorders, so that 
the simultaneous appearance of hemorrhages, joint exudates and 
muscle pains is not to be wondered at (hence the name "pur- 
pura rheumatica"). 

Causes The cause of these disorders is not definitely known. Some 



purpura yy 

cases seem to be due to an infectious agent (bacillus purpura?, 
Letzerich) ; in others a ferment intoxication is probable causing 
chemical blood changes; in still other, more chronic forms, the 
blood vessel walls seem to be particularly affected (endarteritis 
with hyaline or fatty degeneration of the muscular layers and 
fragility of the walls). Some cases seem to accompany chronic 
nephritis, especially with pronounced cardio-vascular manifesta- 
tions ; here again a weakening of the vessel walls engrafted upon 
the hemorrhagic diathesis may be incriminated. 

From a therapeutic standpoint it is very important to dis- Symptomatic 
tinguish true purpura from symptomatic multiple hemorrhages Phases due" 
due to sepsis or accompanying a variety of infections or intox- to sepsis 
ications (small pox, petechial typhus, cholera, plague, yellow 
fever, anthrax, acute yellow liver atrophy, phosphorus poison- 
ing, icterus gravis, snake poisoning, pernicious anemia, etc.). 
In the septic form of multiple cutaneous hemorrhages one fre- 
quently finds ulcerative endocarditis with secondary multiple 
septic emboli in the capillaries of the skin and other portions 
of the body ; there is also a so-called purpura gonorrheica closely 
related to the above. None of these forms constitute true pur- 
pura, although this name is often falsely given them. 

The treatment here must be directed principally against Causal treat- 
the underlying disorder of which the hemorrhages are merely an n ^ ent of tne 
unimportant, and by no means a constant, manifestation. 

The treatment of true purpura, in view of our ignorance in 
regard to its etiology, must unfortunately be largely sympto- 
matic. During the periods of remission that occur, the patient Symptomatic 
should, above all things, be protected from catching cold ; hence SjJJlSjJJJ 1 * ° f 
life in a warm climate is to be recommended whenever feasible. 
Hygienic conditions should be perfect, and above all nervous 
or emotional shock or over-strain should be strenuously avoided, 
for in some cases sudden fright or anger have been known to 
precipitate attacks. 

The treatment of the attack always calls for rest in bed. 
The diet should be bland and should be similar to that described ie 
in the other manifestations of the hemorrhagic diathesis. Cof- 
fee, tea, alcoholic liquors, spices, condiments and all other articles 
that can excite the vasomotors should be omitted. For a time, 
especially in the beginning, milk and cream with some bread 
or cereal and a little lemonade or orangeade should constitute 
the food. 

Particular care should be devoted to the regulation of the Regulation of 

. the bowels 

bowel function, and the stools should be carefullv examined for , , ., , 

Intestinal 
the appearance of blood, denoting intestinal hemorrhage, which hemorrhage 



100 



Sulphuric acid 



Fowler's solu- 
tion 



Ergot 



01. terebin- 
thinae 
Chloride of 
iron 
Hydrastis 



Anti-rheu- 
matic treat- 
ment 



Hemarthrosis 
Serous hem- 
orrhage 
Epistaxis 



would require special treatment (see index). Intestinal para- 
sites, that have been accused of some role in the production of 
the disease, should always be looked for and should be removed, 
if present, as described in the Chapter on Intestinal Diseases. 
There is no specific remedy but, according to most authorities, 
sulphuric acid has been declared a very useful drug. It may 
be given as acid, sulph. dil. in ten to thirty drop doses, or as 
acid, sulph. aromat. in iive to fifteen drop doses, in water, sev- 
eral times a day. Fowler's solution is always indicated and 
should be given as described under Pernicious Anemia. Ergot, 
in the form of the fluid extract, in the dose of ten to thirty 
drops, repeated, is warmly recommended, especially in children. 
Oleum terebinthinse rect. (dose ten to fifteen drops) is endorsed 
by no less an authority than Litten. Chloride of iron in doses of 
one to five drops a day, in milk, or the extract of hydrastis, in 
doses of twenty to thirty drops every three or four hours, are 
also spoken of favorably. 

In all cases of purpura with marked rheumatic manifesta- 
tions (peliosis rheumatica) an anti-rheumatic treatment should 
be instituted, as mentioned in the part on Rheumatism (see 
page 169). It will generally be found that the pain in the 
muscles and tendon sheaths as well as in the joints stops as soon 
as the hemorrhages into the joints occur. The special treatment 
of the hemorrhagic joints (hemarthrosis), of blood extravasa- 
tions into the serous sacs, of nose bleed, etc., that occasionally 
occur in this, as in all the other manifestations of the hemor- 
rhagic diathesis, are discussed in full in the sections on the dif- 
ferent organs affected. 



CHAPTER III. 

DISEASES OF THE DUCTLESS GLANDS 

I. DISEASES OF THE THYROID GLAND. 

MYXEDEMA AND CRETINISM. 

The function of the thyroid gland is either nutritive or 

antitoxic, i. e., it either supplies something to the blood that 

is necessary to normal life or it removes something from it that 

is harmful. Effect . s °/ * e " 

moval of the 

Removal of the thyroid is followed within a few days, or thyroid 
after a longer time (as late as nine months), by anemia and 
oligemia. There is often an initial rise of temperature, usually 
followed by a descent to subnormal. In young animals the 
growth of the bones is retarded and various trophic disturbances 
develop, the rate of respiration increases, a variety of nervous 
phenomena are observed that may be either irritative or de- 
pressive in character, viz., about the motor sphere, fibrillary 
twitching of the muscles followed later by tetany, contractures 
or paresis; and in the sensory sphere, first hyperesthesia and 
later diminished sensibility; and about the heart palpitation 
and tachycardia. Myxedema 

Clinically, a similar syndrome is presented in myxedema 
(synonyms, sporadic or endemic cretinism) and in cretinism 
(synonyms, infantile or fetal myxedema, myxedematous idiotism, 
athyreosis chronica,), as well as in operative removal of the 
thyroid gland {cachexia thyrcopriva if the normal gland is re- 
moved, cachexia strumipriva if the diseased gland is removed). 
The conclusion is, therefore, self-evident that these diseases are 
due to suppression of the thyroid function. 

Here, therefore, the administration of thyroid gland is the 

sovereign remedy and the results obtained from this treatment 

are among the most brilliant achievements of modern medicine. Thyroid ther- 
° . . apy m cre- 

The best results are seen in cretinism. Here the skin soon tinism 

becomes soft and moist, the bloating disappears, healthy growth 
of the bony structures, of the hair and of the soft tissues is 
stimulated, normal development of the teeth sets in and the 
mental condition improves, so that the patients change from 
apathetic semi-idiotic children to energetic and active indi- 
viduals. The younger the subject, the better apparently the 
result, although all ages seem to react favorably. In a very 



♦Portions of this chapter are quoted from my article ou Orgaiio- 
Therapy in "The Reference Handbook of the Medical Sciences" 



102 



MYXEDEMA AND CRETINISM 



In operative 
myxedema 



In endemic 
cretinism 



Administration 
of thyroid 



Distressing 
symptoms fol- 
lowing" thyroid 
medication 



Thyroidism 



small proportion of cases thyroid is without result, and one or 
two cases are recorded in which the disease was aggravated. 
The unsuccessful cases constitute not quite two per cent, of all 
those reported in the literature. As it is not excluded that in 
many of these instances the thyroid preparations employed 
were worthless, this is a remarkable showing and one that war- 
rants the use of thyroid in all cases of myxedematous disease in 
children. Similarly good results are seen in operative myx- 
edema; and in many instances the disagreeable phenomena fol- 
lowing ablation of the thyroid gland could be prevented by the 
administration of thyroid preparations. In the endemic cretin- 
ism of adults the results are not quite so uniform, for in a cer- 
tain proportion of the cases only the main symptoms are re- 
lieved while the minor and probably secondary manifestations 
persist ; thus the edemas may promptly recede while the cachexia 
and the phenomena that are consecutive to the anemia in va- 
rious organs remain uninfluenced by thyroid medication. 

It is usually necessary to continue the administration of 
thyroid for some time; if the remedy has to be stopped tem- 
porarily, for reasons that will be presently discussed, then its 
use must be resumed again, from time to time, otherwise a 
recurrence of the symptoms is apt to supervene. This is due to 
the fact that the use of thyroid is merely a substitution therapy. 
In cases in which improvement is maintained for considerable 
periods after the administration of the remedy has been stopped, 
we must assume that the organism has stored away a certain 
reserve amount of the organ material. As soon as the latter 
becomes exhausted, symptoms of myxedema reappear and the 
recurrence of typical phenomena again calls for the administra- 
tion of thyroid. 

In the infantile form a course of thyroid carried on for a 
sufficient length of time, either continuously or intermittently, 
often leads to a permanent cure, so that the drug can ultimately 
be discontinued. This must be attributed to the fact that the 
substitution of thyroid, by relieving the defective thyroid of an 
amount of labor that it was unable to perform, has enabled it 
to develop up to the demands of the growing organism and ulti- 
mately to assume its normal function; such a favorable result, 
however, is exceedingly rare. 

Not infrequently, as indicated above, a congeries of dis- 
tressing symptoms follows the prolonged use of thyroid that may 
call, for an interruption of the treatment. The manifold effects 
that are attributed to thyroid feeding have been grouped under 
the name of thyroidism (or hyperthyroidism). They are charac- 
terized in extreme cases by pronounced tachycardia, palpita- 



MYXEDEMA AND CRETINISM 103 

tion, sweating, tremor and emaciation; the latter being due to 
increased intracellular oxidation ■ and "accelerated" (?) meta- 
bolism, concerning chiefly the proteids and fats of the body, and 
manifesting itself by an increased excretion of nitrogen, phos-- 
phorus and chlorine. Fever and glycosuria are also occasionally 
observed. The patients develop an enormous appetite and thirst 
and often complain of headache, nausea, vomiting and weakness. 
It is doubtful whether these symptoms are due exclusively to the 
thyroid or whether they are due in part to certain toxic products 
contained in most thyroid preparations; for especially dried 
thyroid powder frequently contains ptomapeptones and pepto- 
toxins that are highly poisonous even in minute quantities. This 
assumption is borne out by the fact that thyroidin (see below) 
rarely produces these s} T mptoms, whereas dried extracts or the 
fresh ( ? ) gland often produce them. 

Fortunately, we are able in cases that develop symptoms of thyroidism 
thyroidism to counteract most of these disagreeable effects by 
the administration of small doses of arsenic, e. g., three to five 
drops of Fowler's solution given during the day. The results 
of this arsenic treatment are really remarkable, and it is prob- 
ably always a safe plan, if a prolonged thyroid treatment is 
contemplated, to give Fowler's solution in the above dose from 
the beginning. 

Various preparations of the thyroid gland are employed. Preparations 
Bircher, in 1889, first implanted a piece of human thyroid gland 
under the skin and in this way produced a prolonged thyroid 
effect with a brilliant result. Grafting of sheep's thyroid has 
been tried in operative myxedema with good effect, but none 
of these methods is, of course, practical. Different extracts of 
thyroid have been prepared with glycerin alone, or with glycerin 
and carbolic acid and thymol; these are administered hypoder- 
mically. Another hypodermic preparation is made by extracting 
thyroid with carbolized physiological salt solution and steril- 
izing the extract by filtering it through clay filters under high 
pressure with carbonic acid gas (method of d'Arsonval). Many 
clinicians advise the use of the fresh gland, raw, by mouth (one- 
eighth to two sheep's thyroids a day). Good results are also 
claimed from the administration of the boiled organ, which is 
more palatable than raw thyroid. Finally, thyroid gland may 
be finely chopped and given in a clysma by rectum. 

The most deservedly popular preparations, nowadays, how- 
ever, are compressed thyroid tablets made from the dessicated 
gland. These are less disagreeable to administer than the other 
preparations mentioned and, if manufactured by a reliable house, 
enable the physician accurately to determine the dose. True, 



104 



EXOPHTHALMIC GOITRE 



very little is known of the amount of active principle which 
they contain, but the same objection applies to all the other 
preparations. As it is essential to strictly individualize in thy- 
roid medication, it is at all events of advantage to know that the 
qualitative and quantitative composition of the tablets is approx- 
imately uniform. As the fresh gland furnishes about 27 per 
cent, of dry powder, each unit of powder corresponds to about 
four times its equivalent in fresh gland. Manufacturers of 
thyroid tablets usually indicate the amount of thyroid powder 
contained in each tablet. The common average dose of the des- 
sicated powder is from one to five grains three times a day. 

The active principle of thyroid gland is iodothyrin* or thy- 
roiodin (not thyroidin which is a name for the extract of the 
gland), a proteid body containing over 9 per cent, of iodine. It 
may be used in the place of the fresh thyroid extract but seems 
unable to replace it in all cases. The dose is from one-third to 
one-half grain (0.02-0.03 gm.) two or three times a day. 



Thyroidism 
and exoph- 
thalmic goitre 



EXOPHTHALMIC GOITRE. 

Many of the symptoms of exophthalmic goitre (Graves's dis- 
ease, Basedow's disease) resemble in their cardinal aspects the 
syndrome previously described (page 102) as thyroidism or 
hyperthyroidism, so that this disease is held to be due to ex- 
cessive activity of the thyroid gland. As a matter of fact many 
of the symptoms of Graves's disease are attributable to an in- 
creased secretion of the thyroid gland. Other features can be 
explained by a qualitative perversion of the thyroid function. 
In addition, however, there are a variety of signs in this disorder 
that can only be explained by some functional derangement of 
the cervical sympathetic and its ganglia, an idea that is borne 
out histologically by the occasional discovery of lesions in this 
portion of the nervous system as well as in the central nervous 
organ, especially in the corpora restiformia. 

The disorder of the thyroid in Graves 's disease is not due to a 
compensatory hypertrophy of the gland caused by relatively 
excessive demands for thyroid secretion as in simple goitre (see 
-page 109), but it is due to an absolute functional hyperactivity 
(and disactivity) with vascular engorgement which leads to the 
entrance into the blood stream of ah excessive quantity of the 
internal secretion of the gland. 

To supply thyroid extract in this disorder is, therefore, alto- 



*It would be of no practical value to discuss in this place the many 
other so-called "active principles" that have been isolated as, e. g., thy- 
reoglobulin, iodoglobulin, etc., etc. 



EXOPHTHALMIC GOITRE 105 

gether irrational and paradoxical. It is unfortunate to record Fallacy of 
that this remedy is, nevertheless, extensively employed in this preparations 
disease either empirically or from ignorance of the physiological in this disease 
.action of thyroid extract. There can be no doubt that thyroid 
always does harm in this disease. There is no case on record 
of true Graves's disease in which thyroid medication was of 
benefit, and there are many cases on record in which it did 
serious harm. 

Of recent years, the serum and the milk of thyroidectomizecl 
animals has been utilized in the treatment of Graves's disease. Serum of thy- 
The principle underlying this method is at least based on more animals** 1126 * 1 
sound physiological reasoning. The results obtained from the use 
of these preparations are for the present, however, ambiguous, 
And must be interpreted carefully and with great conservatism, 
especially as Graves's disease usually runs its course with many 
spontaneous remissions and intermissions. It is best, therefore, 
to suspend judgment for the present in regard to their efficacy. 

Thymus has been used in Graves's disease with some good Thymus 
results. Again, however, spontaneous remissions and intermis- 
sions must be included in the calculation. As no one has ever 
reported any bad effects from the use of thymus, the prepara- 
tions made from this gland may be tried in conjunction with 
other measures to be presently described. Raw thymus, from 
sheep, may be given, or thymus tablets. The dose of the latter 
should vary from five to fifteen grains two or three times a day. 

The most important general measure to be employed in the 
treatment of exophthalmic goitre is rest, both physical and psy- Rest 
chical, for the disease is frequently characterized by emotional 
-excitement or depression ; therefore the patients should live under 
conditions and among people where they are safe from emotional 
excitement, worry, anger and nervous strain. In most cases it 
is well to take the patient away from home, friends and rela- 
tions for a period of several weeks. A change of scene alone 
often works wonders. 

If a case of Graves's disease is sent to a resort, a low altitude climate and 
should be selected, for it is a common experience that elevations altitude 
over two thousand feet frequently induce severe palpitation. 
Life at a high altitude, moreover, stimulates the nervous system, 
and in view of the hyper-excitability of the whole nervous appar- 
atus in these cases, such stimulation should be avoided. The sea 
shore is never good for these cases, for life by the ocean is detri- 
mental both on account of its stimulating effect upon the nerves 
and on account of the deleterious effect it exercises upon anemic 
patients in general. 

There is much controversy in regard to the proper diet. Diet 



106 EXOPHTHALMIC GOITRE 

Many clinicians recommend a diet consisting largely of vegeta- 
bles, cereals, fruit and milk, with the minimum of meat and 
eggs. Personally I have seen better results from an abundant 
meat and egg diet combined with the above. In Graves's disease 
the general metabolism is usually very active and many of these 
cases rapidly emaciate. The question has not definitely been 
decided by careful metabolic studies whether the disassimilation 
of the fats or of the proteids is particularly increased; at all 
events there is almost invariably a more active proteid metabol- 
ism than normal, as manifested by the increased excretion of 
nitrogen. Consequently, severe cases of Graves's disease should 
ingest more than the normal amount of albumen, otherwise they 
will attack the proteids of their own tissues in order to make 
up the deficit. Above all things in this as in any other disease 
the albumen of the body must be protected and this can only be 
done by supplying a sufficient quantity of albuminous pabulum 
by mouth. The patients, as a rule, feel better and stronger and 
retain their weight if abundant proteid is allowed. It is neces- 
sary, of course, to strictly individualize in this respect and to 
take into consideration the tastes of the patient, his previous, 
habits, the state of the digestion and of the kidneys in each case. 
The objection that a "meat toxemia" develops on such a diet is 
theoretically constructed and not borne out by facts. 
Electricity Electricity should always be given a trial in Graves's dis- 

ease, for considerable advantage accrues to some cases from its 
use. The galvanic current is preferably used, although general 
faradization is recommended by some clinicians, particularly of 
the French school. If the galvanic current is employed a small 
ball electrode, connected with the anode, should be applied below 
the angle of the jaw and slight pressure exercised upwards and 
inwards. The other electrode should be a flat sponge or plate 
applied to the back of the neck at the level of the lower cervical 
vertebra, that is, corresponding to the location of the lower cervi- 
cal spinal ganglia. Often it is of advantage to change the direc- 
tion of the current. The current in the beginning should not be 
stronger than one milliampere and should not be applied for 
more than three minutes at a time. Both sides of the neck should 
be galvanized at each sitting. Later, the strength of the current 
should be gradually increased to three or four milliamperes. At 
each sitting it should be slowly increased and then decreased. 
In this way not only the sympathetic, but also the various nerves 
of the neck that are in close proximity -to it, especially the vagus 
and probably, to some extent, the upper portions of the spinal 
cord are reached by the electric current. Very often it will be 
found that this treatment properly carried out reduces the gen- 



EXOPHTHALMIC GOITRE 107 

eral nervousness of the patient as well as the palpitation and the 
tremor. Galvanization of the thyroid gland itself with a small 
sponge electrode is also often useful. 

Hydro-therapeutic means, unless they can be carried out Hydrotherapy 
under careful supervision in an institution, should be used 
guardedly. They have a place, however, in the treatment of 
Graves's disease. The exact choice of method will depend upon 
the presence or absence of severe degrees of anemia, of digestive 
disorders, of myocarditis or cardiac dilatation and upon the 
reactive state of the nervous system, notably the vaso-motors. 
At all events, severe hydriatic measures, i. e., extremes of heat or 
coid, should never be employed, but rather very mild, soothing 
measures. Most beneficial is immersion of the patient in water 
slightly below the body temperature, as described in the Chapter 
on Heart Disease (see page 26). Salt may be added or car- 
bonated waters may be used (see page 25). The patient should 
lie perfectly still for five or ten minutes in the water, should 
then be rubbed dry with a rough towel, the surface of the body 
treated with alcohol and the patient immediately put to bed. In 
cases that are not very severe, the patients may be wrapped 
in a towel wrung out of lukewarm water, covered with woolen 
blankets and left in this packing for half an hour at a time. It 
is always best to leave the arms out of the packing, as otherwise 
a sense of restraint or uneasiness may be created that in these 
nervous and excitable individuals is decidedly detrimental. A 
Priessnitz compress (see page 51) over the thyroid applied two 
or three times a day for an hour or two at a time sometimes acts 
beneficially. 

The medicamentous treatment of Graves's disease is not very Medicamen- 
satisfactory. If there is much anemia iron and arsenic should tous treat- 
be given, as described under Anemia. The nervous symptoms 
must be controlled with bromides, the best preparations being Iron 
the bromide of soda and the bromide of strontium, both given in Arsenic 

doses of from ten to thirty grains (0.65 to 2.0 gm.) preferably ™ m * es 

. Campnor 
in milk, three or four times a day. Monobromate of camphor, in Hyoscine 

ten grain doses (0.65 gm.) may also be given several times a day. hydro-bromate 
If there is much cerebral excitement, hyoscine hydrobromate, in Valerian 
doses of one-two-hundredth to one-one-hundredth grain, prefer- soda 
ably combined with bromides or with valerian, is useful. An- Aconite 
other remedy that seems to act beneficially in Graves's disease Digitalis 
is phosphate of soda. It should be given in thirty to sixty grain 
doses (2 to 4 gm.) two or three times a day, in plenty of water. 
This drug seems to exercise its effect especially upon the nervous 
mechanism governing the heart. The best remedy for palpita- 
tion and tachycardia, however, is aconite. It should be given 



108 



EXOPHTHALMIC GOITRE 



Iodine 



Surgical treat- 
ment 



Partial thy- 
roidectomy 



Resection of 
the sympa- 
thetic 



m intervals of from one to three hours and in doses of from one 
to three drops of the tincture until the desired effect is produced. 
Patients with Graves's disease may, to advantage, be kept on 
small doses of aconite for almost indefinite periods. Digitalis 
has no place in the treatment of this disease unless there is car- 
diac insufficiency. Even here great care must be exercised, for 
tne constant over-action of the heart in this disorder frequently 
produces myocarditis and here digitalis, as has been shown on 
page 30, is a dangerous drug. While it is possible with digitalis 
to reduce the number of heart beats, it should never be used in 
this disease for this purpose alone, i. e., it should never be given 
in doses large enough to appreciably slow the heart. 

Iodine is another remedy that is commonly used in Graves's 
disease. Just why has never become quite clear to me, unless 
it be that there is a vague idea in the heads of some that iodine 
has something to do with the thyroid. Its employment is men- 
tioned merely because this drug has been very popular in the 
treatment of exophthalmic goitre. Clinically, in my experience, 
iodine and iodides almost invariably do harm in this disease, and, 
as a rule, produce an exacerbation of all the symptoms. 

The surgical treatment of Graves's disease consists either in 
the extirpation of the gland, or of portions of the gland, ligation 
of the thyroid arteries or resection of the sympathetic or its 
ganglia. The results obtained from thyroidectomy in true ex- 
ophthalmic goitre are only partially satisfactory even in the most 
expert hands. The operation has not infrequently been followed 
by very disagreeable consequences, notably about the heart, and 
occasionally death. The operation, however, may become nec- 
essary as an emergency measure if the thyroid enlargement is 
so considerable that dangerous symptoms of pressure upon the 
trachea, the esophagus or adjacent blood vessels or nerves occurs 
and the patient's life becomes endangered from this source. 

Resection of the sympathetic is an operation that theoretically 
is well founded. I have never had an opportunity to follow a 
case of Graves 's disease before and after resection of the sympa- 
thetic or its ganglia in the neck. A critical review of the liter- 
ature and of the various case reports fails to convince me that 
the operation is indicated, because equally good results seem to 
be obtainable with other means.. The operation is certainly not 
without danger, as a number of fatal cases have been reported, 
and if the patients survive the operation, disagreeable symptoms, 
especially about the psychic sphere, seem to develop and to per- 
sist for a long time. Judgment in. regard to the advisability of 



SIMPLE GOITRE 109 

this operation and of partial or complete thyroidectomy, as well 
as an expression of opinion in regard to the exact indications for 
surgical intervention, will have to be reserved nntil we know 
more about this subject. 

SIMPLE GOITRE. 

This disorder, especially simple parenchymatous hypertrophy 
of the thyroid, as frequently seen in juvenile individuals, often 
yields to thyroid medication. If, however, degenerative changes 
are present in the parenchyma of the gland, if the enlargement 
of the thyroid is due to vascular disturbances, as in Graves's 
disease (see page 104), or if it is due to hyperplasia of the in- 
testinal tissues, or to tumor formation, then thyroid treatment 
rarely exercises any beneficial effects. 

In the hypertrophic variety of thyroid swelling in adolescents Rationale for 
we must assume that the thyroid is endeavoring to meet the thyroid 
increasing demands of the growing organism by compensatory 
ov6r-activity. By supplying thyroid we relieve the gland of 
some of this excessive labor, and in this way spare the organ, 
prevent permanent functional inadequacy or degenerative 
changes, and thus enable it to regain its normal function and 
size. In this form very remarkable results are occasionally 
observed from the temporary administration even of small doses 
of thyroid or of iodothyrin. The largest statistics on the subject 
have been gathered by H. G. Wells, who reported 584 cases of 
struma simplex treated with thyroid extract, of which 62 per 
cent, were improved. The best results are obtained in recent 
cases, so that the treatment should be instituted as early as 
possible. The remedy must be continued in small doses (see 
page 103) for a long time, either uninterruptedly or with short 
intermissions, otherwise recurrences are apt to appear. Here, 
again, the simultaneous administration of Fowler's solution in 
small doses is of signal benefit in preventing the disagreeable 
symptoms of thyroidism. 

It is interesting to note that very good results are also occa- 
sionally observed in simple goitre from the administration of 
thymus preparations, preferably given in tablet form, in grad- Thymus 
ually increasing doses (see page 105). 

The indications for the use of other remedies than thyroid 
and thymus, and for dietetic, hydro-therapeutic and electric 
means of treatment, do not differ materially from those de- 
scribed under Exophthalmic Goitre. 

In extreme cases that do not yield to medical means removal 
of the gland, or a portion of the thyroid, often remains the 
nnlv resource. 



110 



ADDISON'S DISEASE 



Organo- 
therapy 
The use of 
supra renals 



II. ADDISON'S DISEASE. 

The treatment of Addison's disease, owing to our uncertain 
knowledge of its pathology, is in a very unsatisfactory state. 
No case of Addison 's disease has ever been cured. The patient 's 
strength must be supported during the attacks of weakness that 
so commonly supervene in this affection, preferably by rest in 
bed and the use of a nourishing diet containing an abundance 
of proteid foods. General tonics, notably strychnia and arsenic, 
may be administered. 

The anemia should be treated like any other anemia. The 
gastro-intestinal symptoms should be treated as described under 
Diseases of the Stomach and Intestine. Particular care should 
be taken in this disease to refrain from the administration of 
strong purges, as otherwise very intractibie diarrheas may be 
induced. Hydro-therapeutic measures, electricity and transfu- 
sion have repeatedly been tried without any determinable effect. 

The use of fresh suprarenal glands and of suprarenal extract 
is always indicated for, in the majority of causes of Addison's 
disease, marked organic changes, frequently obliteration, of the 
suprarenal glands have been discovered. The use of suprarenal 
preparations has, however, never cured a case. In many in- 
stances marked improvement followed the administration of this 
remedy; in an equally large proportion of cases, however, one 
must confess that no appreciable effect could be discovered from 
its use. In those in which the preparation seemed to relieve, 
withdrawal of the remedy was almost invariably followed by 
an aggravation of the symptoms; which demonstrates that the 
suprarenal treatment has some virtue. Here and there in the 
literature is found a case report in which the condition of the 
patient seems to have been rendered worse by the use of supra- 
renal preparations, but this fact should not militate against their 
use in view of the utter inadequacy of all other remedial meas- 
ures. It is difficult, moreover, to conservatively interpret either 
amelioration or aggravation from the use of any remedy in 
Addison's disease, owing to the spontaneous fluctuations in the 
condition of the patient that are so characteristic of this dis- 
order. When one considers that there are hardly one hundred 
well authenticated cases of Addison's disease recorded in the 
literature; that many of them were not studied with accuracy; 
that most of them came under observation at a very late stage; 
that finally some of the suprarenal preparations employed were 
inert; then the conclusion becomes unavoidable that the question 
of suprarenal therapy in this disease can in *»~ ^nse be con- 
sidered settled. 



ADDISON'S DISEASE « 111 

When one considers further that the active principles con- 
tained in the suprarenal gland undergo very radical changes 
in the digestive tract within a short time ; that the percentage of 
hypothetical active principles varies greatly in the different 
glands; then some of these indifferent results may also be 
understood. 

The remedy should, at all events, be given a thorough trial. 
The earlier the disease comes under observation the more apt is 
one to obtain some therapeutic results, at least symptomatically. 
The best preparation to use is the powdered extract. The dose 
•cannot be specified; too much can, however, hardly be given, as 
no untoward effects, excepting some irritative phenomena about 
the stomach or intestine, are ever observed from the administra- 
tion of these preparations by mouth. Some authorities claim to 
nave obtained better results from the use of fresh gland, given 
in doses of two or three glands (from sheep) a day. Adrenalin 
has been used, but the results seen from this remedy are no 
better, probably less favorable, than those obtained from the 
use of the dry extract or the fresh glands. 



CHAPTER IV. 

DISEASES OF METABOLISM 



INTRODUCTION-THE LAWS OF NUTRITION. introductor 

That we may understand the pathology of a disease, and The . la . ws of 
that we may intelligently treat it, it is necessary to understand 
the function or functions a perversion of which it represents. 
In the case of the diseases to be discussed in this chapter it is 
therefore essential to appreciate the fundamental principles that 
underlie metabolism before attempting to treat its disorders. 
The manifold facts that constitute the sum total of our knowl- 
edge of this subject cannot be discussed in full within the com- 
paratively narrow limits of this book.* I will content myself, 
therefore, with describing those elements merely that have a 
direct practical bearing upon treatment. Composition of 

The food of man consists of organic and inorganic constit- 
uents. The former comprise water and a number of inorganic 
salts; the latter a variety of bodies containing carbon, oxygen, 
hydrogen, nitrogen and some phosphorus and sulphur, and classi- 
fied as proteids, carbohydrates and fats. The role of the inor- Inorganic and 
ganic and organic food elements differs; for, whereas the inor- J^ ni ts f0 ° d 
game constituents pass through the body unchanged, the organic 
constituents undergo a number of fermentative and oxidative 
metamorphoses so that they leave the body in the form of highly Terminal 
oxidized, inert, terminal products of which urea, water and car- P roducta 
bon dioxide are the main representatives. 

In this process of oxidative destruction, which can be crudely 
likened to a combustion, and the finer intermediary mechanism 
of which need not be discussed in this place, a certain amount The develop- 
of energy is developed by each organic article of food. To ^ e e ^g.° 
measure this amount of energy or its mechanical equivalent in 
heat or labor, the term calorie has been imported from the realm Definition of a 
of physics; a calorie being the amount of heat required to raise calorie 
the temperature of one kilo** of water one degree Celsius. 

It has been determined that each of the three food classes caloric value 
in process of metabolism (i. e., of assimilation, splitting and of proteids, 
oxidation) generates a definite number of calories, viz., fats 

♦For details I refer to my forthcoming book on "Diseases of Metabol- 
ism" 

(1) **1 Kilo (kilogramme)=2 lb. 3 oz. 2 dr. (avoirdupois). 
1 gramnie=15yo grains (15.432349 grs.). 



114 



DISORDERS OF METABOLISM 



Daily caloric 
requirement 



Law of isody- 
namics 



Proteid mini- 
mum 



Average adult 
requirement 
expressed in 
grammes 
per kilo 



Caloric value 
of different 
articles of food 



1 gramme* of proteid furnishes 4.1 calories. 

1 gramme of carbohydrate furnishes 4.1 calories. 

1 gramme of fat furnishes 9.3 calories. 

It has further been determined that a normal adult requires 
from 30 to 35 calories per kilo of body weight a day in order 
to maintain nutritive equilibrium; i. e., assuming an average 
weight of 70 kilo, 70X30—35, or from 2100—2450 calories 
per diem. Theoretically this caloric requirement can be 
supplied vicariously by proteids, fats or carbohydrates ; actually, 
however, this "law of isodynamics" is not valid; for the pecu- 
liarities of our digestive and assimilative functions, as well as 
the character of our intracellular metabolism, render it impos- 
sible for an individual to subsist on one food class alone. 

Above all a certain amount of proteid is essential. The abso- 
lute minimum lies somewhere between 40 and 80 grammes 
for the twenty-four hours' period. The average amount ingested 
is, however, much larger; the daily quantity of food containing 
from 90 to 115 gm. of albumen (370 to 420 calories), 50 to 60 
gms. of fat (465 to 560 calories), and 400 to 450 gms. 
of carbohydrate (1640 to 1850 calories) representing in round 
numbers a total of from 2500 to 2900 calories. The same ex- 
pressed in grammes per kilo of body-weight signifies that a 
normal average adult requires about 1.5 gm. of albumen, 0.8 
gm. of fat and 7.1 gm. of carbohydrate per diem per kilo. The 
amount of rest and exercise, and the sex (women requiring less 
total calories than men) and many other factors influence these 
figures somewhat. 

In order to perform dietetic calculations that, as will pres- 
ently be shown, are of great importance in the proper feeding of 
sufferers from metabolic disorders, it is necessary to know the 
caloric value of the different articles of food; to do this the 
percentage of albumen, carbohydrate and fat each article con- 
tains must be known. The caloric value can then readily be 
determined by multiplying the grammes of albumen by 4.1, of 
carbohydrate by 4.1, and of fat by 9.3. The following table 
gives the approximate albumen, carbohydrate and fat content 
of the most important common foods. 



(2) *These figures hold good only for pure albumen, carbohydrates 
and fat. The actual amount of caloric value that is placed at the dis- 
posal of the organism by different foods depends, however, largely upon 
the physical properties of these foods, the amount lost in the feces ; i. e., 
their digestibility, assimilability, and a variety of other factors peculiar 
to each individual, so that actually these figures must be modified to 
read: 

1 gramme of proteid furnishes 3.2 calories. 

1 gramme of carbohydrate furnishes 3.8 calories. 

< gramme of fat furnishes 8.4 calories. 



DISORDERS OF METABOLISM 



115 



TABLE GIVING PERCENTAGE OF ALBUMEN, FAT AND CARBOHYDRATE 
IN COMMON ARTICLES OF DIET. 



Animal Foods. 

kind of food. Albumen %. 

Veal, lean, raw 20.0 

Veal, fat, raw 19.0 

Beef, medium, raw 20.5 

Beef, fat, raw 21.0 

Beef, boiled 38.0 

Beef, roasted 32.0 

Meat broth 10.4 

Mutton, medium, fat, raw 17.0 

Pork, raw. fat 14.5 

Pork, raw, lean 20.0 

Ham, lean, cured 21.0 

Chicken 21.0 

Duck 22.0 

Goose 16.0 

Piceon 22.0 

Codfish 82.0 

Salmon (fresh) 21.0 

Trout 19.0 

Caviar 32.0 

Oysters 8.0 

Kidney 18.0 

Liver 19.5 

Tongue (boiled) 15.0 

Tongue (smoked) 21.5 

Bacon 9.5 

Suet 0.5 

Lard 0.5 

Frankfurter sausage 12.0 

Egg (with shell) 12.5 

White of egg 12.7 

Yolk of egg 16.0 

Milk 3.5 

Milk, skimmed 3.1 

Buttermilk 4.0 

Cream 3.6 

Butter 0.7 

Cheese (Swiss. American) 34.0 

Xeufchatel cheese 19.0 

Camembert cheese 25.0 

Vegetable Foods. 

Wheat flour 10.0 

Oatmeal 13.5 

Wheat bread 7.0 

Rve bread 6.0 





Carbohy- 


^at %. 


drate %. 


1.5 




7.5 




1.5 




0.0 




9.15 




8.0 




0.6 




6.0 




37.5 




7.0 




8.0 




2.0 


2.0 


3.0 


2.0 


45.1 




1.0 


0.76 


0.5 




12.5 




2.0 




15.5 


2.0 


1.5 


2.6 


5.0 


0.15 


4.5 


3.28 


17.5 


0.5 


31.5 




76.0 




98.0 




99.0 




40.0 


2.25 


12.6 


0.5 


0.25 


0.7 


32.0 


0.1 


4.0 


4.9 


0.7 


4.8 


0.9 


3.7 


25.0 


3.5 


84.0 


0.6 


11.0 


3.5 


41.0 


1.0 


30.5 


1.5 


1.0 


72.0 


6.0 


67.0 


0.5 


52.0 


0.5 


47.0 



116 



DISORDERS OF METABOLISM 



Albumen %. 

Zwieback 13.0 

Macaroni and noodles 9.0 

Rice 9.0 

Potato 2.0 

Carrots 1.0 

Peas (green) 6.0 

Cabbage 2.5 

Cauliflower 2.5 

Sauerkraut . . . 1.0 

Spinach 3.0 

Asparagus 2.5 

Dried peas 23.0 

Beans 24.5 

Radishes 1.2 

Lettuce 1.4 

Cucumber 1.0 

Sugar 0.5 

Olive oil 

Fresh fruit 0.5 

Mushrooms 2.5 

Beverages. 
Alco- 



Fat %. 
3.0 
0.5 
1.0 
0.2 
0.2 
0.5 
0.5 
0.3 
0.2 
0.5 
0.4 
2.0 
2.0 
0.1 
0.3 
0.09 



95.0 

"6i' 



Carbohy- 
drate %. 
80.0 
77.0 
78.5 
20.5 
8.0 
11.0 
6.5 
4.5 
4.5 
5.0 
2.5 
52.5 
52.0 
3.7 
2.2 
2.2 
96.5 



10.0 

4.8 



hoi %.* 

Beer 4.0 

White wine 

Claret 10.0 

Madeira 20.0 

Port 18.0 

Sherry 17.0 

Champagne 11.0 

Brandy 70.0 

Coffee 

Tea .... 

Cocoa 

Chocolate 



Albumen %. 
4.3 

0.2 

0.2 

0.18 

0.2 

0.2 

0.16 
0.16 
14.0 

5.0 



Fat %. 



0.5 
.0.5 
47.0 
15.0 



Carbohy- 
drate %. 
0.8 
1.6 
11.0 
3.0 
5.8 
5.0 
12.0 

1.4 

1.4 

18.5 

75.0 

This table is used as follows to calculate the caloric value of 
the diet that an individual is eating or to arrange a dietary in 
such a way that it will incorporate any desired quantity of 
calories. Assuming for instance that the individual is eating in 
the twenty-four hours the following articles of food, then the 
amount of albumen, fat and carbohydrate they contain can 
readily be gathered from the table as follows : 



Articles. Albumen. 

50 gm. of roast beef 16.0 

100 gm. of chicken 21.0 

10 gm. of butter 

20 gm. of potatoes 4.0 

100 gm. of oatmeal 13.5 

200 cc. of milk 7.0 





Carbo- 


Fat. 


hydrate. 


4.0 




2.0 


2.0 


8.4 




0.4 


41.0 


6.0 


67.0 


8.0 


10.0 



*One gramme of aicohol has a caloric value of 7 (see page 138). 



DISORDERS OF METABOLISM 117 

50 gm. of lettuce 0.6 0,2 1.7 

100 gm. of cauliflower. . 2.5 0.3 4.5 

,200 gm. of white bread. 14.0 1.0 104.0 

2 eggs at 50 gm 25.0 24.0 1.0 

100 gm. of rye bread.... 6.0 0.5 47.0 

100 gm. of fresh fruit. . 2.5 1.0 55.0 

50 gm. of sugar 0.1 48.0 

50 cc. of madeira 1.5 (20% alcohol) 

Total 112.4 55.8 402.7 

The individual, then, is receiving 112.4 gm. of albumen, 55.8 
gm. of fat, 402.7 gm. of carbohydrates, and 10 gm. of alcohol. 
Expressed in calories : 

Albumen, 114.4X4.1= 460.84 cal. 

Fats, 55.8X9-3= 518.94 cal. 

Carbohydrates, 402.7X4.1=1651.07 cal. 

Alcohol, 10.0X7. = 70.00 cal. 

Total, 2700.85 Cal. 

On a mixed diet of this character the individual, therefore, 
is ingesting food of a total caloric value sufficient to more than 
adequately maintain nutrition ; for, assuming the subject to 
weigh as much as 70 kilo, he would be receiving 2700-^-70=38.5 
calories per kilo, distributed as follows : 

1.6 gm. of albumen 

0.8 gm. of fat 

5.74 gm. of carbohydrate 
per kilo of body weight. This, as shown above, would approxi- 
mate very closely normal requirements. 

Among the diseases of metabolism are included diabetes, The group of 
obesity, gout and the uric acid diathesis, osteomalacia, rachitis ™ S q S ° 1C 1S ~ 
and, in a special sense, chronic rheumatism. In many other dis- 
eases perversions of metabolism occur, but there the metabolic 
derangement is merely one more or less unimportant and, at all 
events, secondary symptom of definite and known underlying 
causes. In the diseases of metabolism proper the metabolic de- 
rangement is the primary event and the determining factor in 
the production of the disease. 

All the diseases of this group, especially diabetes, obesity Interrelation- 
and the uric acid diathesis, are intimately related to one another metaborc^d's- 
pathogenetically, chemically and clinically. In one the per- eases 
Version of the carbohydrate metabolism, in the other of the fat 
metabolism, in the third, of the proteid (nuclein) metabolism 
predominates, and each is characterized by an inability on the 
part of the organism to destroy sugar or fat or albumen (nu- 
cleins) in a normal manner. In this way sugar, fat or nucleins 



118 



DIABETES MELLITUS 



Inadequacy of 
causal treat- 
ment 



General thera- 
peutic indica- 
tions 



and their congeners accumulate and the pictures of diabetes, 
obesity and gout are created. The metabolism of the proteids, 
fats and carbohydrates is, however, so intimately concatenated 
that, as a rule, we witness combinations of diabetes and obesity, 
of diabetes and gout, of gout and obesity, or of all three together. 
Causal treatment, in view of our ignorance for the present 
of the etiology of the diseases of metabolism, and also in view 
of the intangible hereditary element that is so important a factor 
in all functional weakness or perversion of the protoplasm at 
large, is not satisfactory, so that the main therapeutic indica- 
tion is by dietetic means to compensate the defective intracellular 
nutrition, and, at the same time to maintain adequate general 
nutrition. This, as will presently be shown, can be done only 
by employing accurate methods. General hygienic and, above 
all, medicamentous means of treatment in this class of disorders 
play a relatively subordinate part. 



Loss of calor- 
ies in urinary 
sugar 



Dangers of 
routine treat- 
ment 



I. DIABETES MELLITUS. 

The most important element in the treatment of diabetes 
is the regulation of the diet. The main objects to be accom- 
plished are to maintain the general nutrition of the patient, to 
increase his tolerance for carbohydrates and, by implication, to 
reduce or prevent the loss of sugar in the urine. 

I have explained in the preceding section how the caloric 
value of the food can be determined and what amount of calories 
a normal individual requires in order to maintain adequate nu- 
trition. 

In case of diabetes with the loss of valuable unconsumed 
sugar in the urine, a diet that would adequately feed a normal 
individual does not furnish the body with a sufficient caloric 
value, and as a result the patient, once the deficit is not sup- 
plied, consumes his own tissues and emaciates. Here, therefore, 
whenever possible, a metabolic study should be undertaken in 
order to determine this deficit. Whenever this can be done it 
is of inestimable value, provided the figures obtained are in- 
terpreted with conservatism. 

With the introduction of calorimetric methods, however, into 
the treatment of diabetes the danger of substituting an ultra- 
scientific routine for the old-fashioned and venerable, though 
altogether unscientific, routine of feeding every diabetic on a 
diet containing no starches or sugars, has been created. For 
the clinician the proper treatment of the case has only begun 
when the metabolic study is completed; as, to him, individual pe- 
culiarities and divers complicating factors that determine devia- 



DIABETES MELLITUS 119 

tions from the metabolic schedule must be included in the calcu- 
lation. It is well to realize, moreover, that the general prac- 
titioner cannot perform these metabolic studies in each case of Difficulties of 
diabetes that comes under observation. He has neither the metabolic °cal- 
time nor the facilities, nor possibly the training, nor, above all. culations 
in most cases the co-operation of the patient to do this work; 
for to properly carry out a metabolic study the patient should 
be under absolute and rigid control for several successive days, 
or better, weeks, preferably in a hospital. Nevertheless before 
discussing the practical methods that can be employed, and that 
have evolved from an immense number of accurate studies, the 
principles that underlie such a metabolic calculation may be 
briefly described, for they should be familiar to every physician. 
The following case report (quoted from the author's "Clinical 
Urinology, " page 73) may serve as an illustrating prototype of 
a metabolic study in a case of diabetes : 

Mrs. W. P. Weight 60* kilo. Calories required for adequate m etabolic° cat- 
nutrition, 60X35=2100. dilation in 

Average diet on six successive days : 

Proteids 150 150 gm.X4.1= 615.0 cal. 

Carbohydrates 190 gm.X4.1= 779.0 cal. 

Fats 110 gm.X 9.3=1023.0 cal. 



Total calorie intake=2417.0 cal. 

The patient's daily average sugar ex- 
cretion on four successive days on 
this diet was 160 gm. This 
amount calculated in calories must, 
therefore, be deducted as fol- 
lows : 

Average daily sugar excretion 160 gm.X4.1= 656.0 cal. 



Calories utilized=1761. cal. 

Instead of receiving, therefore, the full caloric value re- 
quired, i. e., 2100 cal., the patient, owing to the loss of sugar, 
only utilized 1761 cal., although the diet represented 2417 
cal. This means a deficit of 2100—1761=339 cal. And these 
deficient calories unless furnished in additional food must be sup- 
plied from the destruction of the patient's proper tissues. 

One can further readily calculate what proportion of thi«. 
deficit was made good from the albumin of the patient's tissue. 



*The figures are given in round numbers throughout in order to facil- 
itate the calculation. 



120 



DIABETES MELLITUS 



Vicarious 
feeding 



Necessity of 
supplying 
some carbo- 
hydrate 



what from the fat (for the patient lost weight on this diet), 
and the diet can be regulated accordingly. All one has to do 
is to determine the nitrogen output in the urine and feces, 
and compare it with the nitrogen intake (food nitrogen). 

This patient, for instance, received in the daily diet 150 
gm. of albumin, and as albumin contains 16 per cent, of nitrogen, 
this amount contained 24.0 gm. of nitrogen. On this diet the 
patient excreted a daily average of 23.7 gm. of N. in the urine, 
and 3.01 gm. of N. in the feces, making the total N. output 
23.7-|-3.1=26.8 gm. of N. The nitrogen output, therefore, was 
greater by 2.8 gm. (26.8—24=2.8) than the N. intake, and this 
excess must have been derived from the patient's own albumin. 
These 2.8 gm. of N. are contained in 17.5 gm. of albumin 
( 2.8 X 100-^16=17.5 ). 

As 17.5 gm. of albumin can produce only 7L75 calories 
(17.5X4.1=71.75), there still remain 268.25 (339—71.75= 
268.25) of the 339 deficient calories to be accounted for. As 
these must have been derived from the patient's fat, one can 
readily determine by dividing 268.25 by 9.3 (the caloric value 
of one gramme of fat) that 268.25-^-9.3=28.8 gm. of the pa- 
tient's fat were consumed. 

The patient, therefore, on a diet valued at 2417 calories, i. 
e., considerably more than the calculated value necessary to 
adequately nourish a normal subject of 60 kilo (2100 cal.), lost 
17.5 gm. of her own albumin and 28.8 gm. of her own fat. 

If it were true that a diabetic could use none of the sugar that 
enters the blood stream, the question of feeding such a case would 
be theoretically a very simple one. One would have to exclude 
the carbohydrates and replace them by proteids and fats of 
sufficient caloric value to make up the caloric deficit. In the 
case which is quoted, for instance, the patient would have to 
receive 17.5 gm. of albumin and 28.8 gm. of fat, in addition to 
the proteids, fats and carbohydrates enumerated in the above 
diet. 

As a matter of fact only a small minority of cases of diabetes 
are altogether unable to utilize any of the sugar. These are 
very grave instances that are fortunately rare, and would be 
still less frequent if many milder cases were not transformed 
into grave ones by injudicious dieting. The great majority of 
patients can utilize some of the sugar and it is generally bad 
practice to withhold this food permanently; for aside from the 
glycosuria, the digestive function, the comfort of the patient, 
and above all the formation of acetone bodies (see below) must 
be considered. 



DIABETES MELLITUS 121 

In order to know how much sugar these patients can safely The boundary 
take without over-taxing their sugar metabolism, it is, however, ° r a s S iSlation 
necessary to determine, as a preliminary step, the tolerance of 
each case for carbohydrates, or the so-cal]ed boundary of assim- 
ilation, and to feed the patients accordingly. 

In order to do this the patient is given what may be called Diabetic test 
a diabetic test meal. This consists of a series of articles that 
are free from carbohydrates, plus a weighed portion of some 
carbohydrate food. The following table incorporates the most 
important carbohydrate free articles of food that can be used to 
arrange such a test meal. I give this diet list in this place in 
full, because, as will be presently shown, the articles included 
therein must often be utilized to the exclusion of everything else 
in the treatment of diabetes (see Table II). 

TABLE. II.* 
ARTICLES OF FOOD PRACTICALLY FREE FROM CARBOHYDRATES. 

Fresh Meats. — All the muscular tissues of mammals and 
birds, braised, boiled or roasted with their own gravy, with but- 
ter, with meal or flour ; fresh mayonnaise or other sauces made 
without flour — warm or cold. 

Inner Parts of Animals. — Tongue, heart, lungs, brain, calf's 
spleen, kidney, marrow. Liver of calf, game and poultry up to 
100 grammes weighed after eooking). 

External Paris of Annuals. — Feet, ears, snout and tail of 
all edible animals. 

Conserved Meals. — Dried and smoked meats, smoked and 
salted tongue, pickled meats, ham. bacon, tinned meats. 

Sausage. — All varieties, if free from bread or flour. 

Fresh Fish. — All fresh and salt water fish, boiled or grilled 
or served with flour-free sauce. Fresh melted or browned but- 
ter may be taken at the same time. If the fish is cooked in bread 
crumbs, the latter should be removed before eating. 

Conserve el Fish. — Dried, salted, or smoked fish, such as cod, 
shell fish, herring, mackerel, sole, plaice, salmon, sprats, eels, 
etc. : also pickled herrings, sardines in oil, mackerel in oil, an- 
chovies, sardellen. tunny. Caviar. 

Mussels and Crustacea. — Oysters, mussels, lobster, crab. 

Eggs.— From all birds, raw or cooked in various ways, but 
without added flour or meal. 

Fats. — Of animal or vegetable origin, e. g., butter, lard, fat 
of roast meats, margarine, olive oil, usual salad oil, cocoa butter, 
goose fat. Cod liver oil. 



♦Quoted in part from von Xoorden, "Diabetes." 



122 DIABETES MELLITUS 

Cream. — Good fat, rich cream, sweet or sour, as drink or 
added to solid foods or to drinks up to about 200 cc. a day. 
For cooking purposes cream may be substituted for flour when 
making special dishes of meat, fish, vegetables and eggs. 

Fresh Vegetables. — Salads; lettuce, endives, cress, dandelion,, 
purslane. 

Aromatic Herbs. — Parsley, dill, thyme, pimpernell, mint,, 
leek, garlic, celery. 

Fruits, Roots and Stalks. — Gherkin, tomato, young green 
beans, vegetable marrow, onions, radishes, white and green as- 
paragus, hops, Brussels sprouts, celery (except the root), young 
rhubarb sprouts. 

Blossoms and Flowers — Cauliflower, Brussels sprouts, arti- 
choke. 

Leaves. — Spinach, sorrel, cabbage, red beet. 

Fungi. — Fresh mushrooms, truffles in usual quantities. 

Fruits. — Bilberries, unripe gooseberries, when prepared with 
saccharin instead of sugar. 

Conserved Vegetables. — Asparagus, haricot beans, cut beans,, 
salted gherkins, pickled gherkins, peppered gherkins, mixed 
pickles, sauerkraut, olives, champignons and any prepared vege- 
tables of those groups already mentioned. 

Condiments. — Salt, white and black pepper, cayenne, pap- 
rika, curry, cinnamon, clove, nutmeg, English mustard, saffron,, 
caraway, caper, vinegar, citron. 

Soups. — Meat soups prepared from fresh meats or meat ex- 
tracts, with the addition of green vegetables, asparagus, eggs,, 
fragments of meat, marrow, liver, Parmesan cheese or other 
foods contained in this fable. 

Sweets. — Prepared from eggs, cream, almonds, citron, gela- 
tine, saccharine being substituted for sugar. 

Drinks. — All varieties of spring and seltzer water. Good 
brands of brandy, rum, arack, whisky, and other fruit spirits. 

Wine. — All the well-known table wines (white and red) are 
almost sugar free — at all events those that have been kept for 
three or more years in casks. Bordeaux and Burgundy wines 
come under this category. White Rhine and Moselle wines are 
also free from carbohydrates. 

Tea, Coffee and Cocoa. — "With cream, but with saccharine 
substituted for sugar. 

Lemonade. — Seltzer water with lemon juice, sweetened with 
saccharin or glycerin (hevulose may be used especially if per- 
mitted). 



DIABETES MELLITUS 123 

A very convenient diabetic test meal can be selected from 
the above articles. The following one I use almost as a routine 
in these determinations: 

TYPE OF DIABETIC TEST MEAL. 

For Breakfast — 

Two soft boiled eggs. 

150 cc. of weak tea with a tablespoonful of cream. 

A beefsteak, weighing (cooked) 100 grammes. 
For Dinner — 

Bouillon with one egg. 

Boiled or fried fish and broiled chicken, the two together 
weighing (cooked) not more than 250 grammes. 

A little celery. 

Boiled onions. 

Cauliflower. 

Lettuce salad with plenty of oil dressing. 

A cup of weak tea or coffee with a tablespoonful of cream. 

About 30 grammes of Neufchatel or Camembert cheese. 
For Slipper — 

Two boiled eggs. 

Cold asparagus, or tomatoes, or lettuce salad with plenty of 
oil dressing. 

A little bacon. 

A cup of weak tea with two tablespoonfuls of cream. 

If a patient is placed upon this diet for forty-eight hours, 
and if at the end of that time the urine is sugar free, then one 
is dealing with a mild form of diabetes and it now becomes nee- Method of de- 
essary to determine how much carbohydrate food the patient v,o^^Jtf f 
can tolerate without excreting sugar. This is done by adding tolerance 
white bread to the above test meal, beginning preferably with 
100 grammes during the first day, distributed over two meals 
in 50 gramme quantities, and increasing this bread ration each 
day by 50 grammes until sugar appears in the urine. Thus, 
if a patient on one day excretes no sugar after eating 3X50=150 
gm. of bread, and on the next day passes sugar on 4X50=200 
gm. of bread, then we say that the boundary of assimilation lies 
between 150 and 200 gm. of white bread. The diagnostic and 
therapeutic importance of knowing this boundary of assimila- 
tion, or the tolerance for carbohydrates, will presently be dis- 
cussed. 



124 



DIABETES MELLITUS 



The three de- 
grees of 
diabetes 

The first de- 
gree, mild 
diabetes 



Two categories 
of mild 
diabetes 



The second 
degree, dia- 
betes of medi- 
um severity 



Three groups 
diabetes of me- 
dium severity 



For practical therapeutic purposes it is convenient to dis- 
tinguish three degrees of diabetes that may be determined as 
follows : 

In the first category, the mildest forms of diabetes, the sugar 
should disappear within two days after complete withdrawal of 
carbohydrate foods, i. e., as soon as the patient is placed upon 
the carbohydrate-free test meal mentioned above. To the cate- 
gory of mild cases also still belong those instances in which the 
patients fail to excrete sugar when there are added to this carbo- 
hydrate-free diet from 100 to 150 grammes of white bread. 

From a clinical standpoint it is important to distinguish 
among these mild cases of diabetes two groups, viz., those form 
that occur in persons past middle age or old individuals and 
those that occur in very young people. The prognosis in the 
former class of cases is always better than in the latter. In- 
dividuals of the first type are usually moderately obese and 
commonly show some evidences of the uratic diathesis. In the 
young cases the neurotic type predominates, and unless great 
care is exercised in these individuals, they are apt to develop 
into the medium or the severe type of diabetes. 

To the second category of cases, diabetes of medium severity, 
belong those instances in which complete withdrawal of carbohy- 
drates is necessary for at least two or three weeks before the 
sugar completely disappears from the urine. Among these cases 
of medium severity several groups must be distinguished for 
practical reasons. 

There is one group of cases in which the withdrawal of 
carbohydrates not only causes the disappearance of sugar within 
two or three weeks, but also produces much general improvement 
in the condition of the patient, an increase of weight and a dis- 
appearance of acetone bodies from the urine (disappearance of 
Gerhardt's ferric chloride reaction). 

In a second group of cases, the withdrawal of carbohydrates 
again leads to the disappearance of sugar from the urine, but 
in the beginning there is considerable loss of weight, the patients 
feel weak and Gerhardt's reaction either appears for the first 
time or increases in intensity. Within a few days, however, 
after the disappearance of the sugar a change for the better 
occurs, the weight again increases, the patients recover their 
sense of well-being and the Gerhardt reaction disappears. 

In a third group of cases, finally, the condition becomes ag- 
gravated at once, and while the sugar may disappear the patients 
rapidly begin to lose weight and complain of great weakness ; it 
the same time the Gerhardt reaction appears and rapidly in- 
creases in intensity. In addition, such patients commonly de- 



THE LIGHT FORM OF DIABETES 125 

velop digestive disorders and diarrhea. This last group of cases 
forms the transition to the third. or severe type of diabetes and 
should be treated accordingly. • 

In the third category, the severe type of diabetes, finally, The tnird de ~ 
the sugar does not disappear, even if the patients are placed diabetes 
for weeks or months upon a carbohydrate-free diet, showing that 
these individuals are unable to consume even that proportion of 
sugar which is generated within their own tissues from the dis- 
integration of their own albumens. Here the sugar does not 
disappear from the urine until the food albumens are consider- 
ably reduced, indicating conclusively that the albumens may be 
a very prolific source of sugar, a fact of great practical im- 
portance and one that is often overlooked (see page 128). In 
the most severe type of diabetes, finally, it is altogether impos- 
sible to cause the disappearance of the urinary sugar, even when 
the patients are starved, i. e., when all food is withdrawn. 

The prognosis and the treatment of these three classes of General con- 
diabetes varies radically and each type must be discussed sepa- relati^^to 5 
rately. In the light cases, and in the cases of medium severity, prognosis and 
the main object of treatment must be to cause the disappearance t h e three de- 

of the sugar from the urine; for in this way the tolerance for ffrees of 

diabetes 
carbohydrates can ultimately, as a rule, be increased and com- 
plications removed ; whereas if the glycosuria, thanks to careless 
dieting, is allowed to persist, the cases almost invariably become 
aggravated. The complete withdrawal of carbohydrates is, 
however, rarely necessary as a permanent procedure, as will be 
presently shown. In the severe cases less attention should be 
paid to the glycosuria and more to maintaining the general 
nutrition of the diabetic patient. 



DIETETICS OF TPIE LIGHT FORM OF DIABETES. 

In this class the principle of sparing those organs that are "Besting" and 

concerned with the metabolism of sugars must be enforced exercism S" 

the sugar 

and here the plan can be adopted of first "resting" the metabolism 
sugar metabolism, so to say, for short periods of time by the 
complete withdrawal of carbohydrate food from the diet, and 
then gradually adding carbohydrate foods to the diet to "exer- 
cise ' ' the sugar-destroying functions back to normal. It is hardly 
necessary in most cases to keep such patients for long on a 
carbohydrate-free diet. 

They should be placed at first upon a diet containing no Technique 
carbohydrate foods (see Table II). During this period great 
care should, however, be exercised to furnish enough calories 
to adequately nourish the patient. This can usually be accom- 



126 THE LIGHT FORM OF DIABETES 

plished without difficulty by supplying abundant fat. Should 
the patient begin to lose flesh upon the restricted regime, despite 
the ingestion of enough calories, or should very ]arge quantities 
of acetone and its congeners, oxybutyria and diacetic acid appear 
in the urine, then the restricted diet is to be abandoned and 
some carbohydrate must be administered. Even if no untoward 
symptoms appear, however, it is generally better after four to 
six weeks of restricted diet to allow the patients some carbohy- 
drate food for the sake of their appetite and general comfort; 
besides it is much easier to manage these cases, and above all to 
supply adequate caloric values in the food, if some bread, pota- 
toes, rice or other starchy food is allowed. 

Before the addition of carbohydrates to the diet of such 
cases the boundary of tolerance should be very carefully de- 
termined, as described above (see page 123). They should now 
be kept for a time upon a ration containing no more white 
bread than corresponds to an amount that is somewhat below 
the established boundary of tolerance. 

Should sugar reappear again, then the amount of carbohy- 
drate food should at once be reduced or stopped altogether until 
the urine becomes sugar-free again. If the patient bears the 
addition of white bread well for several weeks, and if no glyco- 
suria supervenes, then he may safely be kept on this amount of 
white bread, or its equivalent (see Table III), for many weeks 
or months at a time. From time to time a period of restricted 
diet should again be instituted and the boundary of tolerance re- 
established. 
Equivalents of The following table indicates various articles of food con- 

white bread taining an amount of carbohydrate that corresponds to that con- 
tained in 100 gm. of white bread. 

TABLE III. 

THE CARBOHYDRATE CONTAINED IN 100 GM. OF WHITE BREAD IS 

EQUIVALENT TO THE CARBOHYDRATE IN: 

2 litres of milk or buttermilk. 

120 gm. of rye or graham bread. 

200 gm. of aleuronat or gluten bread.* 



*DIABETIC BREADS. — Most so-called diabetic breads contain ap- 
proximately 50 per cent of carbohydrate. The vegetable albumens 
(aleuronat, roborat, plasmon, gluten) all contain about 5 per cent of car- 
bohydrate. These breads are made from such flours plus a certain 
amount (one to four parts) of ordinary flour. They should only be used 
as equivalents for white bread in the proportion of about 2* to 1. Their 
indiscriminate use, which is so popular with the laity who imagine that 
these breads can be safely taken ad libitum, is therefore to be con- 
demned as dangerous. They fulfill a useful purpose, however, owing to 
the fact that twice as much of the various diabetic breads can be 
eaten as of ordinary white or rye bread and still no greater amount of 



THE LIGHT FORM OF DIABETES 127 

70 gm. of zwieback. 

100 gm. of chocolate. 

80 gm. of chestnuts (peeled). 

80 gm. of flour (wheat, rye, barley, buckwheat). 

70 gm. of rice. 

70 gm. of noodles or macaroni. 

70 gm. of oatmeal. 

120 gm. of dried peas, beans, lentils. 

200 gm. of green peas. 

360 gm. of new potatoes. 

280 gm. of old potatoes. 

240 gm. of fresh apples, pears, plums, apricots, cherries, 
grapes. 

400 gm. of strawberries, raspberries, gooseberries, blackber- 
ries, cranberries, huckleberries. 

100 gm. of figs. 

6 bananas. 

6 peaches. 

Two handfuls of walnuts, hazelnuts, almonds. 

1-3 litre of Port, Sherry or Madeira. 

1 1-3 litres of beer. 

It is clear that such large quantities of any one of these 
articles should rarely be eaten in place of bread. I have given 
these equivalents for one hundred grammes of white bread 
chiefly for the sake of convenience in calculation. 

Milk, bread, potatoes, cereals, diabetic breads, a little beer The different 
and the other articles enumerated above may be allowed spar- a rt ^ les of 
ingly, provided their carbohydrate content is included carefully 
in the calculation in such a way that for each gramme of thes^ 
articles that is permitted a corresponding amount of white bread 
is withdrawn. 

In this way one should succeed in keeping these patients 
permanently sugar-free and not infrequently in practically 

carbohydrate be administered. This is an advantage, inasmuch as the 
bulk of the bread satisfies the craving of the patient for bread, and, at 
the same time, enables him to ingest a larger amount of butter than if 
half the quantity of white bread were permitted. According to the same 
principle it is often of advantage to give diabetics very porous, fluffy 
breads on account of their bulk; for they satisfy the appetite if they are 
cut in thin slices and buttered freely, and, above all, they satisfy the 
eye and the mind without injuring the stomach or the carbohydrate 
metabolism. Still another bread for diabetics, that contains very much 
less carbohydrate than either ordinary white bread or bread made from 
gluten flour and wheat or rye flour, is almond meal bread made from 
ground almonds, containing about 7 per cent of carbohydrate, with the 
addition of butter, eggs, salt and spices. Unfortunately this bread is 
not very palatable, tastes more like cake than bread and hence is not 
well tolerated for an indefinite time by most diabetics. 



128 



DIABETES OF MEDIUM SEVERITY 



Substitutes 
for sugar 



curing them; at least to such an extent that they, at the expira- 
tion of a year or so, can exist upon a fairly liberal diet from 
which only a few articles are to be, for all time, rigidly excluded. 
Among the latter are pastry, honey, ice cream, preserves, candy 
and sugar. 

Unfortunately the various substitutes for sugar (see page 
138) that we have do not seem to satisfy the majority of patients, 
so that for the sake of comfort it will nevertheless usually be- 
come necessary from time to time, as a concession to the patient 
but always with the exercise of careful control, to allow a little 
of sugar or of other sweets. 



Technique 



Low boundary 
of tolerance 



Danger of too 
much albumen 



Average meat 
and fat ration 



Addition of 
alcohol 



DIETETICS OP DIABETES OF MEDIUM SEVERITY. 

The cases belonging to this category must be handled with 
much more care than the light cases. The patients should at 
once be placed for at least two months upon a carbohydrate-free 
diet and after the degree of tolerance, provided they can tol- 
erate any carbohydrate, is established at the expiration of this 
time the addition of carbohydrate food made very gradually 
and kept up for a short time only. This rule is self-evident, be- 
cause sugar will almost invariably appear in the urine within a 
week or two after the use of starchy foods is resumed. Broadly 
speaking, this invariably constitutes an indication to return to 
the carbohydrate-free diet. It will usually be found that the 
boundary of tolerance in these cases is very low, i. e., that they 
cannot stand more than about 50 grammes of white bread, or its 
equivalent, without developing glycosuria. 

In such cases, moreover, particular care must be exercised 
that they, do not eat too much albuminous food. The fact is 
not sufficiently appreciated, as stated above, that albumen may 
become a very prolific source of urinary sugar and that the ad- 
dition of an excess of albuminous pabulum to a mixed diet un- 
doubtedly in many cases reduces the tolerance for carbohydrates, 
whereas the restriction of albuminous food often increases this 
tolerance. Excessive meat-feeding, besides, favors the devel- 
opment of acidosis. 

The average meat ration, therefore, should never exceed an 
amount containing 150 grammes of albumen (see Table I), 
whereas the amount of fat should approximate about 200 
grammes. If a certain amount of alcohol (see page 138), about 
70 to 80 grammes, is added to the diet, and this is usually a. 
very good plan in this type of diabetes, then the patient re- 
ceives approximately 3,000 calories in his food, that is, about 



DIABETES OF MEDIUM SEVERITY 129 

500 calories more than the average requirement and enough 
usually to compensate for any slight loss of sugar that may oc- 
cur in the urine. If no alcohol is given the fat ration may be 
increased by 40 to 50 grammes. 

Occasionally it is impossible in this class of cases to produce 
complete disappearance of the sugar from the urine, even after 
the patients have been on a carbohydrate-free diet for nearly 
two months. In a case of this kind a very useful plan is the Starvation 
one suggested by Naunyn, viz., to starve the patients completely 
for a period of twenty-four hours, giving them during this 
time merely a little tea or coffee or bouillon, and plenty of water. 
After the fast the patient is placed for two or three weeks upon 
a carbohydrate-free diet, and it will frequently be found that 
now the sugar remains absent from the urine and that some 
tolerance for carbohydrates has been acquired. 

In view of the fact that no individual can, without great _ . 

' to Intermittent 

suffering, great discomfort and some danger, exist indefinitely carbohydrate 
upon a diet consisting exclusively of albumens and fats, it gen- ee 1Iig 
erally becomes necessary, sooner or later, to administer, even 
here, some carbohydrate food, even at the risk of promoting 
glycosuria for the time being. This plan should, therefore, be 
adopted intermittently, immaterial whether the carbohydrate- 
free diet caused a complete disappearance of sugar from the 
urine or not. Such patients, however, should never receive more 
than 100 grammes of white bread, or its equivalent, in the 
twenty-four hours. 

The transition from the carbohydrate-free diet to the more G ra a ua i tran- 
liberal diet should always be very gradual and the patients sition from 
should receive each day a little more of the carbohydrate food until d \f j. 
the 100 gramme limit is reached. If it is found that the glycosuria 
rapidly increases, then the carbohydrates should be gradually 
reduced and finally stopped again. It is usually a good plan Chan g"e m kind 
to alternate the kind of carbohydrate food, i. e., to give for drate food 
some days bread, then its equivalent in potatoes or rice or oat- 
meal, etc., and to give onlv a single carbohydrate at a time; 
/» o ! t i i hit Tne advan- 

ior the mixture of several carbohydrates generally leads to a tag-es of sin- 
greater excretion of sugar than the administration of a single §^ + ^ a £k°ky^ 
one. Each individual, moreover, reacts differently to different 
carbohydrates, so that tolerance determinations with oatmeal or 
rice or potato often reveal peculiar relations that may be ad- 
vantageously employed in the treatment. 

Based on this fact so-called "cures'' for diabetes by feeding with 
large quantities of single carbohydrates have at different times been ad- 
vocated. Thus we have had the potato cure, of Mosse, the rice cure, of 
von Diihring, the milk cure, of Winternitz, and more recently the oat- 
meal cure, of von Noorden. All these observers are reliable clinicians 



drate feeding 



130 



DIABETES OF MEDIUM SEVERITY 



Oatmeal cure 



Uesults 



and good observers and all of them have reported a few cases that were 
decidedly benefited by this method of feeding. This is particularly 
striking, as the use of large amounts of carbohydrate food in diabetes 
is in itself paradox, and especially as the good results w T ere as a rule 
observed in cases that were of the severe type, and in which the ordi- 
nary methods of dietetic, hygienic and medicinal treatment had failed. 
The oatmeal cure seems to yield proportionately better results than any 
of the other plans of feeding, and as I, personally, have had experience 
witn the oatmeal cure alone, I will limit my remarks to it. 

The method of administering the oatmeal cure (as recommended by 
von Noorden) is the following: 250 gm. of oatmeal are cooked for 
several hours in water, to which a little salt is added ; while the por- 
ridge is boiling, about 100 gm. of butter are added and later, after the 
boiling is completed and the mess is cooled, about 100 gm. of egg albu- 
men, or a like amount of some vegetable albumen, may be added to 
the porridge while it is still on the fire. This soup is administered about 
every two hours during the day in such quantifies that the whole amount . 
is eaten in the course of twenty-four hours ; in addition, the patient is 
oermitted to take some brandy or claret and water or a little strong, 
black coffee. 

It will readily be seen that it is impossible to continue this mode of 
dieting for a long time; the patients naturally soon acquire a distaste 
for the oatmeal soup and when this period comes the treatment will have 
to be stopped, as it is worse than useless to force it. , 

The results from this treatment are either brilliant within tbe first 
few days after it is begun, as manifested by a great reduction or the 
complete disappearance of the sugar and the acetone bodies from the 
urine, or they are altogether negative from the start. Therefore, in 
my experience, if good results— striking results — are not seen within 
three days it is probably better to discontinue the oatmeal cure and to 
resort to other measures. I have seen one or two bad consequences that 
I think can be attributed to the prolonged use of the oatmeal cure after 
an appreciable effect failed to appear within two or three days. This 
group of patients suffered a reduction of their tolerance for other carbo- 
hydrates, and above all, developed alarming degrees of acetonuria. 

I am not as yet prepared from my own experience to state percent- 
ically how many cases are benefited, how many are not affected favor- 
ably, and how many are harmed by the oatmeal cure. I venture the 
statement, however, that if the rule is observed to stop the oatmeal 
cure if no good effects are seen within three days, the number of bad 
results will be reduced to insignificant figures. In about 35 per cent, 
of all my cases I have had good results, varying from a slight reduc- 
tion of the acetonuria and a considerable reduction of the urinary 
sugar during the time the oatmeal treatment was administered, to 
remarkable improvement in very serious cases in which the sugar prac- 
tically disappeared, the gain in weight was rapid and the reduction of the 
acidosis almost instantaneous, and in which, moreover, the after-effects 
of the "cure" were determinable for months after the patient had left 
the hospital. 

It is interesting and important to note, as well, that the best results 
are obtained in juvenile diabetes, a form that is particularly intractable 
to ordinary methods of treatment, and that is particularly damaged by 
the old-fashioned routine treatment of feeding on a starch- and sugar- 
free diet. No case of juvenile or adolescent diabetes should be deprived 
of the benefits of an oatmeal cure. At the least the trial should be 
made, and if the "cure" fails, no harm will have been done, provided 
it is properly carried out and not forced after the third day if no 
results appear within that time. 



THE SEVERE TYPE OF DIABETES 131 



DIETETICS OF THE SEVERE TYPE OF DIABETES. 

In view of the fact that it is impossible in this form of diabetes 
to cause the complete disappearance of the sugar from the urine, 
even when the albumins of the diet are greatly reduced, espe- Technique 
cial care must be taken to compensate for the loss of sugar by 
increasing the ingestion of albumins and fats, for only in this 
way can adequate nutrition be maintained. For this reason less 
attention must needs be given to reducing the glycosuria than 
to maintaining the body weight, treating complications symp- 
tomatically and rendering these unfortunate cases comfortable. 
In this variety of diabetes, to which belong most of the juvenile 
cases, acidosis (and the excretion of acetone bodies) is usually Acidosis in 
very pronounced. This generally constitutes a danger, because tnis tyP e 
in a large proportion of cases coma seems to be more liable to 
occur when the acetone body excretion is great than when it is 
absent or small, although there are many exceptions to this 
rule. Exclusive meat-fat feeding seems to favor acidosis and it 
will be found that the addition of carbohydrates to the diet of 
such cases often, although not invariably, causes a considerable 
reduction in the acetone-body excretion. If, therefore, such pa- 
tients develop marked degrees of acetonuria, with oxybutyric and 
diacetic acid and much ammonia in the urine, then, above all, 
the exclusive meat-fat diet should be discontinued and, for the 
sake of safety and as a prophylactic measure against coma, 
carbohydrate food should be given even at the risk of increasing 
the glycosuria. 

In this class of cases carbohydrates, however, have practic- carbohydrates 
ally no food value, because they are promptly re-excreted in of little food 
the urine. They must be considered merely as a welcome addi- 
tion to the diet and one that enables the patient to eat enough 
of the necessary albumens and fats to maintain nutrition. It 
will often be found that the complete withdrawal of carbohy- 
drates not only destroys the appetite, but produces digestive dis- 
orders that are often fatal in their consequences. In general, 
these patients should be allowed considerable albuminous food The albumen 
up to 150 grammes, the maximum of fat, considerable alcohol and fat ration 
and, in addition, about 50 to 60 grammes of bread or its 
equivalent. This liberal feeding should be interrupted from 
time to time by placing the patients for two or three or more 
weeks upon a rigid diet; then the carbohydrate portion of the 
food should again be gradually increased. One will often be 
gratified even in these severe cases to find that their tolerance 
for carbohydrates is greater after such a period of carbohy- 
drate withdrawal than before. In this type of diabetes, par- 



132 



THE SEVERE TYPE OF DIABETES 



The liquid 
intake 



Smoking, 
chewing and 
atropine to al- 
lay thirst 



Fallacy of 
"forbidden" 
and "allowed" 
"diabetic 
diet." 



Inaccuracy of 
studies on drug 
effects in 
diabetes 



The sugges- 
tive element 



ticularly, careful metabolic studies, preferably carried out in an 
institution, are often of inestimable value in prolonging life. 

The amount of fluid in this class of cases should be regulated 
in such a way that the specific gravity of the urine, broadly 
speaking, is kept up to, or brought down to, 1025. The liquid 
intake should in general be proportionate to the ingestion of 
albumens and the corresponding excretion of urea; for the urea 
largely determines diuresis. Excessive water drinking is to be 
condemned in severe diabetes on account of the danger of gas- 
tric dilatation and of the strain upon the heart and arteries 
that results from the abundant ingestion of water. Very often 
diabetics acquire the habit of drinking large amounts of liquid. 
They should be educated to control this craving and if neces- 
sary may be advised to chew gum or smoke a little in order to 
deaden the sensation of thirst. Atropine sulphate in one-two- 
hundredth grain doses also, often fulfills a like purpose. 

It will be seen from all that has been said that the exact 
regulation of the diet in diabetes must vary according to the 
type and the degree of the disease, and according to individual 
peculiarities, the presence or absence of complicating diseases, 
the age of the patient and his ability or willingness to submit 
to rigid control. Consequently no mathematical formula, no 
"Diabetic Diet" giving "forbidden" and "allowed" articles 
can be arranged for feeding every case of diabetes. Until very 
recently the dangerous routine habit of placing each case of 
diabetes for indefinite periods upon a diet containing no carbo- 
hydrates was universal^ in vogue. As a result innumerable 
diabetics were literally starved to death. Nowadays we have 
learned, as shown above, that a diabetic not only can, but should, 
in the great majority of cases, at least from time to time, enjoy 
the benefit of carbohydrate feeding. 

MEDICAMENTOUS TREATMENT OF DIABETES. 

A large number and a great variety of remedies have at 
different times been recommended for the cure of diabetes. 
None, however, can exercise a curative effect upon the dis- 
ease proper and only a few appreciably influence the excretion 
of sugar. Most of the reports on the effect of the different 
medicines that have been used in diabetes have been made 
without sufficient dietetic control, and for periods of time that 
were far too short to rule out the uncertainties that always 
arise in regard to the effect of a remedy in a disease that is 
subject to so many spontaneous fluctuations as diabetes. In 
interpreting, furthermore, the efficacy of any drug in diabetes, 
a disorder that, especially in its milder forms, is so markedly 
influenced by emotional and psychic states (see page 146), the ele- 
ment of suggestion must always be considered, particularly, 



THE SEVERE TYPE OP DIABETES 133 

when a new drug of much vaunted efficacy is tried for the first 
time. 

Some of the remedies that are actually capable of reducing 
the glycosuria act by curtailing the appetite and by interfering 
with the assimilation of food. As soon as a patient, owing to Remedies that 
such a drug effect, eats less food, especially carbohydrate or pgtife^and de- 
albuminous food, then the sugar excretion may very readily be- range the 
come reduced; incidentally, however, serious harm may be done lges 10n 
the patient, owing to the malnutrition and the irritation of the 
gastro-intestinal tract, or the liver, that is produced by the 
medicine. Other remedies, again, exercise a beneficial effect 
upon certain functions of the liver, the cardio-vascular appa- 
ratus, and, above all, the nervous system, so that they possibly General tonics 
improve the general condition of the patient, act as a general 
tonic and hence actually enable him to destroy more sugar than 
before. These effects are, however, as will readily be under- 
stood, very indirect and in most cases transitory. One should, 
therefore, be especially careful not to place too much reliance 
on drugs in the treatment of diabetes, nor to misinterpret a 
temporary reduction in the sugar excretion as due to the drug 
effect alone, for otherwise the temptation may be created to 
neglect the all-important dietetic treatment. 

The fact that there is not, so far as we know to-day, any 
proper anti-diabetic remedy should not, however, discourage us 
from using those drugs that we know to be capable of favorably 
affecting the general health of the patient, counteracting or 
remedying complications or, above all, removing distressing or 
dangerous symptoms, chief among them the glycosuria. To 
enumerate all the drugs that have been recommended would 
be futile, so that only those may be discussed in this place that 
have empirically vindicated their claims to usefulness in the 
treatment of diabetes. 

Chief among the valuable drugs are opium and its alka- opium and its 
loids. By the aid of opium the last traces of sugar can, with- alkaloids 
out doubt, often be removed from the urine in cases that do 
not become altogether sugar-free on a restricted diet. In cases 
of medium severity particularly, that are existing upon a re- 
stricted diet, but that still excrete some sugar, it often reduces 
the glycosuria. It does not, however, seem to exercise any ap- 
preciable effect upon the sugar excretion in diabetics who are 
eating carbohydrate foods. The effect of the drug can never be 
absolutely relied upon and its action is always uncertain; for 
occasionally it exercises no influence at all, even in the cases 
specified above. Its effect is never permanent; for when its 
use is stopped the glycosuria reappears and usually increases 



134 



THE SEVERE TYPE OF DIABETES 



Dose and ad- 
ministration 



Action of 
opiates 



Nervous seda- 
tives 
Bromides 
Chloral 
Phenacetin 
Sulphonal 
Valerian 



Salicylic acid 
preparations 



Mode of action 



Contra-indi- 
cations 



rapidly, only to disappear again, everything else remaining 
equal, when opium is resumed. Many patients rapidly wear 
the drug out, so that the dose must be continuously increased 
if its effect upon the sugar excretion is to be maintained. Herein 
lies the chief danger from the use of opiates, especially if the 
patients know what they are taking. 

The dose should be large from the beginning, i. e., at least 
half a grain (0.03 gm.) of the extract should be given three 
or four times a day, preferably in combination with the extract 
of belladonna, one-twelfth grain (0.005 gm.) or atropin sulphate 
one one-hundredth grain (1 mg\). Some clinicians prefer co- 
deine, others morphine in appropriate doses, but, in my experi- 
ence the best effects are undoubtedly obtained from the extract 
of opium administered as above. 

It is probable that opiates act chiefly by their sedative power 
and not by any specific effect upon the carbohydrate meta- 
bolism, although some investigations seem to indicate that opi- 
ates interfere with the disassimilation of the tissue albumens 
and hence prevent the organism from splitting off sugar mole- 
cules from the tissue proteids. This would explain their good 
effect in patients living upon a carbohydrate-free diet in which 
the urinary sugar is undoubtedly derived from the catabolism 
of the albumens proper. 

A number of other remedies have been given for their seda- 
tive effect upon the nervous system, chief among them, bromides, 
chloral, phenacetin, sulphonal, valerian, etc. Many of these 
drugs undoubtedly act beneficially in the neurotic or neuras- 
thenic types of the disease (see page 146), but in most cases they 
are inert and do more harm than good by irritating the gastric 
mucosa and deranging the digestion. 

Next in importance to the opiates are the preparations of 
salicylic acid, given either as sodium salicylate, in doses of from 
ten to thirty grains (0.6 to 2 gm.) or as aspirin, in doses of 
from thirty to forty grains (2 to 3 gm.) several times a day, 
after eating. These drugs act differently than the opiates, for 
their effect becomes apparent precisely in those cases that are 
eating some carbohydrate food; they seem to increase the 
boundary of tolerance for carbohydrate foods, and thus enable 
the patient to utilize more of the alimentary starches. These 
drugs, too, should be given in large doses, as indicated above, 
in order to do any good. They are strictly contra-indicated in 
diabetics suffering from gastric or renal disorders; and as many 
diabetics, especially of the severe type, suffer from these com- 
plications, their usefulness is limited. Some skeptics go so far 
as to claim that the salicylate preparations do good chiefly by 



THE SEVERE TYPE OF DIABETES 135 

deranging the stomach and hence interfering with the proper 
assimilation of food, and that they reduce the glycosuria in 
this way, simply because, upon their administration, less of 
the ingested carbohydrate pabulum is absorbed. It is hard to 
disprove this criticism. 

Jambul occasionally acts very well in diabetes in a manner j an rt> u i 
similar to the salicylates, i. e., it aids in increasing the boundary 
of tolerance. Its action, however, is very uncertain and its 
effect transitory. One can never predict in advance, therefore, 
whether or not jambul is going to be effective. Patients, more- 
over, wear this drug out very rapidly, so that if it is adminis- 
tered at all, it should be given interruptedly, i. e., for two or 
three weeks at a time and then not again until after an inter- 
vening period of at least four or six weeks. Leading authorities 
report sufficiently good effects from the use of jambul to warrant 
its trial in every ease that does not satisfactorily yield to dietetic 
treatment, opium or salicylates. The drug may be given in the Dose and ad- 
form of the dry powder in the dose of five to thirty grains (0.3 to ministration 
2 gm.) three or four times daily in capsules, gradually increas- 
ing the quantity until as much as an ounce (32 gm.) is given 
a day. A much more reliable and pleasant preparation is the 
maceration with water which may be prepared as follows:* 
200 grammes of dried jambul fruits, including the seeds, are 
finely powdered and macerated in two litres of water (to which 
10 gm. of salt and 4 gm. of salicylic acid are added) at 37° to 
40° C. The watery extract is filtered off and 100 cc. of the 
fluid taken cold every morning on an empty stomach, and the 
same dose again in the evening before retiring. The salicylic 
acid is added merely as a preservative. 

Alkalies are always useful in diabetes and I have made it Alkalies 
a practice to give from five to thirty grains of sodium bicarbon- 
ate, or of calcium carbonate, two or three times a day to every 
case of diabetes for indefinite periods of time. Alkalies in the 
first place effectively aid in counteracting the acidosis that is 
so frequently met with in diabetes; in this sense a continuous 
alkali therapy may be considered a useful prophylactic measure 
against the development of severe acidosis, which notoriously Mode of ac ti n 
often leads to the development of coma. Aside from their effect 
upon the acid intoxication alkalies must also be considered an 
hepatic stimulant (page 496), and there is much experimental 
evidence to show that they increase intracellular oxidation and 
hence, we must assume, promote the destructive metabolism of 
circulating carbohvdrates. 



*Von Noorden. 



136 



THE SEVERE TYPE OF DIABETES 



Mineral 
waters 



Life in Carls- 
bad, Marien- 
bad, Vichy. 



Dangers of Re- 
sort treat- 
ment 



Iodide of 
potash 



Mercury 



The effects occasionally derived from the use of many of 
the mineral waters, natural or artificial, that are so popular 
in the treatment of diabetes, must in large part be attributed 
to the alkalies they contain. To this category belong especially 
waters like Vichy, Marienbad and Carlsbad. 

It is important, however, to appreciate that the benefits de- 
rived from a sojourn in Carlsbad or Marienbad or Vichy, or 
any of the other watering places, can only in part be attributed 
to the effect of these alkaline waters. The resort treatment of 
diabetes of certain types is without doubt highly beneficial; but 
this is due in great part to the careful regulation of the diet 
which can be carried out without hardship to the patient in 
such resorts; to the respite from worry and from the strenu- 
ous business life; to the out-door existence and the pleasure de- 
rived from a vacation in a pleasant watering place; not to speak 
of the benefits that accrue to the patients from placing them- 
selves under the care of resort physicians who are usually par- 
ticularly skilled and experienced in the management of this 
disease. There is one danger in the resort treatment of diabetes, 
viz., that many cases, particularly of the lighter type, imagine 
that a few weeks in Carlsbad, Marienbad or Vichy under a 
careful regime will neutralize the bad effects accruing from in- 
judicious dieting during the rest of the year, so that many pa- 
tients imagine that they can divorce themselves from all restric- 
tions, provided they return to the resort for some months each 
year. This form of optimism is to be seriously discouraged. 
That the drinking of the waters in these resorts alone does not 
produce the beneficial effects in diabetes is made very apparent 
by the indifferent results obtained from their use if they are 
taken at home, bottled, or in the form of artificial salts. 

Iodide of potash sometimes acts beneficially in diabetes, par- 
ticularly in two types, viz., those that are due to arteriosclero- 
sis, possibly involving the arteries of the pancreas, and those 
that are due to syphilis (central lesions, syphilitic pancreatitis or 
hepatitis). The remedial action of iodides in arterio-sclerosis 
has been fully discussed in the section on this disorder. Their 
good effect as antiluetics is self-evident. Every case, therefore, 
presenting evidences of arterio-sclerosis, or presenting a sus- 
picious syphilitic history, should be given the benefit of an 
energetic iodide treatment, care being taken, of course, above 
all things that the stomach and intestine are not deranged (see 
Syphilis). 

Mercury seems to act less beneficially in diabetes due 
to syphilis. This must be attributed to the fact that the diabetic 
manifestation in syphilis is always a late sign, presumably due 



THE SEVERE TYPE OF DIABETES 137 

to arterial changes involving the central nervous system or the 
pancreas and producing degeneration of portions of these or- 
gans. Iodide of potash can here possibly be effective, whereas 
mercurials are usually without effect. Bichloride of mercury 
has been recommended, but the drift of opinion among reliable Bichloride of 
clinicians seems to speak against its efficacy. Given hypoder- mercur y 
mically it not infrequently produces disagreeable sequelae, owing 
to the vulnerability of the skin and subcutaneous tissues in 
diabetes and the tendency in this disease to the development of 
skin lesions. Its use, therefore, had better be eschewed. 

Various drugs have been recommended whose efficacy should Intestinal anti- 
be attributed to their action as intestinal antiseptics, and symp- se P tlcs 
tomatically they occasionally do good. To this group belong creosote 
lactic acid, creosote and other phenol preparations. Their effect Phenol prep- 
is very uncertain and very little benefit generally accrues from ara tions 
their use. 

General tonics, such as quinine, arsenic and iron, are com- Quinine 
monly used in diabetes. They occasionally improve the anemia Arsenic 
and possibly stimulate the nervous system to ^icreased activity, ron 
but I have never been convinced that they exercise any appre- 
ciable effect upon the course of diabetes nor upon the amount 
of sugar excreted in the urine. 

Organo-therapy on theoretical ""rounds should be efficacious Organo- 
therapy 
in diabetes. However seductive the use or pancreas prepara- 
tions or of combinations of pancreas with muscle- or with liver- 
or with salivary gland-extract may appear, practically nothing Pancreas alone 
of definite value has so far been observed from their adminis- with liver, 

tration. Pancreas is occasionally useful, as will be shown in muscle > sa j 1_ 

^ 7 vary glands 

another paragraph, in the treatment of the steatorrhea of dia- 
betes, but it has no effect upon the glycosuria. I reported some 
oases in which the boundary of tolerance seemed to be raised 
by the use of pancreas-muscle extracts,* but observations made 
subsequently in a larger number of cases have failed to support 
the first observations. Liver extracts and brewer's yeast have Liver extracts 
been used, but the optimistic claims advanced in the beginning 
have never been vindicated, although yeast often favorably in- 
fluences the furunculosis of diabetes. Nevertheless organo- Brewer's 
therapy appears to be a very hopeful field and while nothing 
tangible has so far been accomplished, we may hope some day 
to discover an efficient organo-therapeutic method of combating 
diabetes. 

Among the drugs that may, finally, be used in the treat- Substitutes 
ment of diabetes may be mentioned some of the preparations 
that take the place of sugar. To this group belong chiefly 

♦New York Medical Journal, 1904. 



138 



THE SEVERE TYPE OF DIABETES 



Saccharine 

Dulcin 

Crystallose 



Levulose 



Alcohol 



saccharine, dulcin and crystallose. Saccharine is the sulphonid 
of benzoic acid and is three hundred times sweeter than ordinary 
sugar. In very small quantities, therefore, it is often useful 
to sweeten coffee, tea and lemonade, preserves and other des- 
serts. It also forms an important constituent of a variety of 
diabetic relishes, wines, candies, etc. The patients, however, 
soon tire of this remedy and argue that while it is sweet it 
does not take the place of sugar; moreover, it has been shown 
that saccharine is not without effect upon the kidneys, for it 
not infrequently produces irritation of the renal epithelia. It 
should, therefore, be given carefully, occasionally stopped and 
replaced by crystallose or by dulcin. The latter remedy, para- 
phenol carbamid, is not so sweet as saccharine; moreover, it 
irritates the liver and occasionally produces icterus. Its taste, 
however, is more agreeable than that of saccharine. I have 
frequently used the drug without ever seeing any bad effects 
from so doing, provided it is not given in doses of more than 
2 gm. a day. 

Occasionally a patient who is altogether intolerant to dex- 
trose can take levulose for a time with impunity. If this is 
the case the latter sugar is an invaluable aid in feeding diabetics. 
Before administering it one should carefully determine, how- 
ever, the boundary of tolerance of the patient for this sugar.* 
If alimentary glycosuria follows its administration promptly, 
then it must be considered as dangerous as dextrose and should 
be discontinued. 

Alcohol possesses a high caloric value, one gramme furnish- 
ing 9 calories. As a food, therefore, it can, to a limited ex- 
tent, replace other articles (see page 116). 

100 calories are furnished by: 

14.3 gm. of alcohol (lOO-f-7) 
10.75 gm. of fat (100—9.3) 

24.4 gm. of proteid (100-=-4.1) 
24.4 gm. of carbohydrate (100—4.1) 

As the digestion of fats is usually improved by taking a lit- 
tle alcohol, preferably in the form of brandy or whisky, alco- 
hol is particularly useful as a stomachic in diabetes and as a 
substitute for some of the fat in cases that are living upon a 
meat-fat diet. As a general heart and nerve tonic it also has 
its place, especially in patients who have been used to some 
alcoholic stimulant all their lives. In such individuals, especially 
if they are advanced in years, the withdrawal of alcohol is decid- 
edly bad practice. More than forty to fifty grammes per diem, 
however, should rarely be allowed. 



*For the normal boundary of tolerance for different sugars see 
Croftan : "Clinical Urinology," pg. 65. 



THE SEVERE TYPE OF DIABETES 139 

EXERCISE IN DIABETES. Importance of 

In addition to the dietetic and medicament ous treatment of ™?2 llar ex ~ 

ercise 

diabetes one should recognize that certain other elements in 
the general management of the disease are of great import- 
ance. Thus the amount of exercise that a diabetic takes should 
be carefully regulated. Muscular exercise by increasing the 
carbohydrate metabolism in the muscles is, in certain cases, capa- 
ble of reducing the glycosuria. Light muscular exertion, par- 
taking of the character of out-door sports, is always to be 
preferred to in-door calisthenics or forced exercises; for, in the 
former case, the pleasure derived from the exercise, i. e., the 
joyful psychic stimulation as well as the out-door life, both 
act beneficially. No violent exercise should be permitted, for 
in diabetes any over-strain is dangerous. The amount of exer- 
cise should be made altogether dependent upon the general nu- 
trition of the patient, the condition of the heart, the blood ves- 
sels, the kidneys and the nervous system. er5se°by thf" 

The urine should always be carefully inspected in order to urine 
control the effect of exercise. As soon as the nitrogen excre- 
tion increases muscular exercise should be reduced or stopped; 
for, whatever benefits are to accrue from muscular exercise 
should become manifest by an increased destruction of sugar, 
i. e., by a reduction of the glycosuria, and not by an increased 
destruction of body albumen, i. e., by an increased excretion of 
nitrogen (urea). In order to obtain the optimum effect from 
exercise it is best to administer the carbohydrate ration, in cases 
living on a semi-restricted diet, immediately before muscular 
exercise is indulged in, and to continue the exercise for an hour 
or two thereafter; for it has been shown that during muscular 
exercise more of the sugar is consumed and utilized than during 
periods of rest. Massage 

If gymnastics or out-door exercises are contra-indicated on 
account of complications about other organs, then massage occa- 
sionally produces a very beneficial effect upon the excretion 
of sugar and the general well-being to the patient, although its 
effects are not by any means so striking nor so reliable. Here, 
again, the carbohydrate ration can to advantage be administered 
before the massage treatment is applied. In the severe type 
of diabetes very active muscular exercise must be eschewed. 
Such patients should be advised to lead a quiet life, both physic- 
ally and psychically, for, in severe diabetes, as has been re- 
peatedly stated, any strain and unrest, either emotional, mental 
or physical, should be avoided. 



140 



COMPLICATIONS AND SEQUELS OF DIABETES 



Stomatitis 
Gingivitis 
Pyorrhea 
Caries of teeth 



Toilet of the 
mouth 



Fetor 



Bleeding 1 and 
painful gums 



TREATMENT OF THE COMPLICATIONS AND SEQUELAE OF DIABETES. 

Most of the complications of diabetes disappear with a re- 
duction of the glycosuria and an improvement of the general 
condition of the patient. Sometimes a more rigid diet must be 
ordered for a time, on account of complications, than would 
otherwise be administered, so that a mild type of diabetes, for 
instance, must be treated like a case of medium severity. Occa- 
sionally, however, it becomes necessary to employ special meth- 
ods for the relief of very obstinate, very distressing or particu- 
larly dangerous symptoms. 

The stomatitis gingivitis, pyorrhea, the loosening and caries 
of the teeth may be due either to localized infections or to 
tropho-neurotic influences. These mouth manifestations are 
among the most distressing symptoms of diabetes and it is im- 
portant that every case of diabetes should, from the beginning, 
be instructed carefully in regard to the possibility of mouth com- 
plications, and taught how to attain mouth asepsis and to per- 
form the proper toilet of the teeth and gums. After each meal 
a diabetic should rinse his mouth and cleanse his teeth, prefer- 
ably with a 3 per cent, solution of sodium carbonate in warm 
water to which may be added as a flavor a few drops of the 
tincture of eucalyptus or a little menthol. Mechanical irregu- 
larities of the teeth should be corrected early, by choice during 
the aglycosuric period. All articles of food that can mechan- 
ically scratch or injure the gums and very hot beverages should 
be forbidden. A hard tooth brush should never be used. 

Excessive fetor may be corrected by using the following 
mouth wash : 



9 



Beta-naphthol, 
Sodium biborate, 
Pepermint water, 
Distilled water, 
M. Sig. Apply locally. 
If the gums are painful and bleeding the following mouth 
wash is useful: 



0.2 gm. 

20.0 gm. 

200.0 cc. 

1000.0 cc. 



3 



Tincture of opium, 20.0 cc. 

Chlorate of potash, 

Biborate of soda, each, 10.0 gm. 

Decoction of marshmallow root, 1000.0 ce. 
M. Sig. Apply locally. 



COMPLICATIONS AND SEQUELS OF DIABETES 141 

The care of the skin is always of great importance in diabetes Skin lesions 
on account of the tendency shown in this disease to the devel- 
opment of furunculosis,* erysipelatous infections, acne, eczema 
and gangrene. Lukewarm baths, preferably with the addition 
of soda or of salt, are exceedingly useful. Following such a 
bath the patient's skin should be carefully dried with soft 
warm cloths and treated with cocoa butter or oil. Severe rub- 
bing, owing to the vulnerability of the skin, should always be 
avoided. Patients with diabetes should frequently change their 
underwear and the greatest cleanliness of the surfaces of the 
body should be promoted. 

Pruritis, either general or localized, especially about the Pruritus 
genitals, is one of the earliest, most distressing and most ob- 
stinate symptoms of diabetes. General pruritus is presumably 
due to irritation of the cutaneous nerves by circulating sugar. 
In most cases its intensity fluctuates with the degree of glyco- 
suria and the symptom frequently disappears without further 
interference when the urine becomes sugar-free, only to reap- 
pear again, however, when more liberal carbohydrate feeding 
is instituted and the hyperglycemia increases. The best remedy 
for internal use and almost a specific is sodium salicylate, in 
doses of thirty grains (2 gm.) several times a day. Local appli- 
cations are of very little value in general pruritus. 

In pruritus around the genitals, due in many cases to the 
development of fungi {mycosis vulva) and usually due to 
leptothrix, the reduction of the glycosuria, sodium salicylate 
internally and anodyne powders or ointments applied locally 
usually relieve. A 5 per cent, cocaine ointment or a 3 per cent, 
eucaine ointment, or a dusting powder containing 10 per cent, 
of orthoform, combined with frequent washing of the parts 
without rubbing or scratching, usually promptly produce re- 
lief. 

Dyspeptic symptoms arising in the course of diabetes always Dyspeptic 
call for particular attention. First, because diabetics more s y m P toms 
than sufferers from any other disease are dependent for the 
maintenance of their existence upon an intact gastro-intestinal 
tract. Second, because dyspepsia, especially in severe types 
of diabetes, is frequently a precursor and a determining factor 
in the development of coma. Dyspeptic symptoms not uncom- 
monly arise from monotonous, one-sided feeding, e. g., from 
an excessive meat-fat diet, or simply from over-loading the 
stomach with food (polyphagia) or water, with resulting func- 

♦Yeast internally is in some cases an efficient remedy against diabetic 
furunculosis. (See page 137.) 



142 



COMPLICATIONS AND SEQUELAE OF DIABETES 



Gastric irri- 
tation 



Catarrh of 
the bowel 



Fatty diarrhea 



tional over-taxation and mechanical dilatation of the stomach 
with all that entails. 

In very severe cases of gastric irritation the best plan of all 
is to withdraw food completely for a period of twenty-four 
hours, allowing merely a little broth or diluted milk or a little 
claret in water, at the same time feeding the patient by rectum 
(see p. 367). In order to allay the gastric hyperalgesia and the 
vomiting, cerium oxalate in ten grain doses, frequently re- 
peated, or cocaine, as described on page 19, or 2 per cent, chloro- 
form water should be given, while cold or hot applications, ac- 
cording to the likes of the patient, should be applied over the 
epigastrium. The severe thirst that usually appears during the 
period of food- and drink-restriction can, to some extent, be 
mitigated by allowing these patients to chew gum, to swallow 
small pieces of ice at frequent intervals, or even to smoke a 
little. 

After this rest cure for the stomach the patient should be 
put for a day or two upon milk and gruels composed of almond 
meal or gluten-flour and then gradually the broad dietary re- 
sumed, care being taken all the time that the maximum of food 
is introduced by rectum in order to maintain general nutrition. 

The more chronic dyspeptic disorders in diabetes call for 
careful analysis of the gastric function and for treatment that 
does not materially differ from that described in the Chapter 
on Diseases of the Stomach. 

Catarrh of the bowel is always serious in diabetes. Acute 
catarrh with profuse diarrhea should be attacked most energet- 
ically in every case; for the interference with food assimilation 
that results, rapidly weakens the patient and not infrequently 
directly precipitates coma. Bismuth subnitrate in doses of fif- 
teen to twenty grains (1 to 1.3 gm.), with extract of opium one- 
half grain, and tannic acid suppositories containing about three 
grains (0.2 gm.) of the drug, should be given at frequent in- 
tervals until the diarrhea is checked. An attempt should be 
made to feed the patient by mouth as soon as the bowel move- 
ments are controlled. During the diarrhea brandy and water 
should be frequently given by mouth, in small doses, by prefer- 
ence ice cold, both to support and, in a measure, to nourish the 
patient. 

Fatty diarrhea (steatorrhea) is not uncommon. Here pos- 
sibly the involvement of the pancreas and hepatic insufficiency 
can be held responsible for the condition. The fats in the diet 
should be reduced. Sodium carbonate or calcium carbonate, in 
ten grain (0.65 gm.) doses with pancreatin or ox-gall, of each 



COMPLICATIONS AND SEQUELiE OF DIABETES 143 

five grains (0.3 gm.), should be administered at frequent in- 
tervals during the day. 

Obstinate constipation is also often a troublesome and a dan- Constipation 
gerous complication. It, too, not infrequently precipitates coma 
if allowed to persist. Here absorption of bowel poisons from 
stagnation and putrefaction of bowel contents must be accused 
of determining the attack of coma. Usually abundant fat-feed- 
ing and the restriction of carbohydrates suffice to counteract the 
constipation. . Saline waters or a lemonade made of 

Glycerin 3 parts, 

Citric acid 5 parts, 

Water 1,000 parts, 
the whole quantity to be administered in divided doses during 
the day, are all useful measures. 

The best medicines to counteract the constipation in diabetes 
are rhubarb and soda mixtures, either Mistura Rhei et Sodaa two 
drachms to three ounces (8 to 100 cc.) or the following powder: 

F> 

Rhubarb root, 

Sodium bicarbonate. 

Sulphur, precipitated, of each 10 grains (0.6 gm.) 

M. Sig: To be taken at night, preferably in milk. 

If these measures do not regulate the bowels, then castor oil 
or the Compound Infusion of Senna may be used to advantage. 

Complicating affections about the heart and arteries, the 
lungs (tuberculosis) and the kidneys that arise in the course of Complications 
diabetes must all be treated according to the principles described heart, arteries, 
in other chapters. It will rarely become necessary to deviate lungs, kidneys 
materially from the general dietetic schedule on account of these 
complications. The simple rules that should be occasionally ob- 
served have been mentioned in the text. If evidence of severe 
renal disease appears, especially if the cardio-vascular apparatus 
becomes involved, then the diabetes must be relegated to sec- 
ondary importance, and the treatment should be chiefly directed 
towards the cardio-renal disorder according to the principles 
laid down in the Section on Nephritis (see page 204f). The com- 
plication of diabetes with obesity, and diabetes with the uric 
acid diathesis, are discussed in their appropriate places. Obesity and 

Among the most distressing secondary symptoms of diabetes gou 
are the neuralgias, especially about the sciatic nerve and the 
brachial plexus; and a variety of other nervous disorders mani- Neuralgias 
festing themselves either as sensory or motor disturbances, or, 



144 



COMPLICATIONS AND SEQUELS OF DIABETES 



Trophic dis- 
orders 



Prevention of 

coma 



Treatment of 
the attack 



above all, as trophic disorders. Among the latter perforating 
ulcer and gangrene, herpes, pemphigus and glossy skin, brittle- 
ness of the nails, loss of hair and teeth and diabetic neuritis may 
be mentioned. 

The symptomatic treatment of the neuralgias is rather un- 
satisfactory, for the ordinary anti-neuralgic remedies rarely suf- 
fice to control the pain. The best combination of drags, in my 
experience, is quinine and opium, given as follows : 

Quinine sulphate, 10 grains (0.65 gm.) 

Extract of opium 14 grain (0.0015 gm.) 

M. Sig. In a capsule repeated three or four 
times a day. 

Antipyrin, in five grain (0.35 gm.) amounts, is also occasion- 
ally of service, especially as it seems to exercise some effect upon 
the glycosuria. Generally speaking, the majority of the nervous 
disorders yield spontaneously if the hyperglycemia can be re- 
duced, so that attention should chiefly be directed towards the 
treatment of the underlying diabetic disorder. 

coma. 

The administration of alkalies throughout the course of 
diabetes as a prophylactic measure against coma has already 
been mentioned (see page 135). With the appearance of the first 
signs of coma, especially in cases that have been living for some 
time upon a rigid meat-fat diet, some carbohydrate food should 
at once be administered. I have even occasionally practised the 
intravenous injection of levulose, a sugar that some diabetics can 
burn with facility (see page 134), and I can testify from personal 
experience to an occasional good sj^mptomatic result from this 
practice. Inversely, coma may sometimes be averted in a patient 
living upon a very liberal diet by great restriction of the carbo- 
hydrate food. The sudden withdrawal of carbohydrates from 
the diet, i. e., placing the patients at once upon a meat-fat diet 
is always dangerous ; for coma has many times been produced by 
this course. We are unable to explain these peculiar, apparently 
paradoxical phenomena, but empirically they are certainly true. 

In fully developed coma the patients are usually semi-con- 
scious or comatose; there is generally severe vomiting and other 
gastro-intestinal disturbance, so that dietetic rules, even if they 
would lead to any result, could not be carried out. The treat- 
ment here lies along different lines. Diabetic coma is always 
an exceedingly dangerous and usually a fatal complication, and 
almost all the measures that we can employ unfortunately merely 
fulfill the purpose of partially reviving the patient and post- 
poning the fatal issue for a short time. The patient in the first 
stages of diabetic coma should be put to bed and forced if pos- 



COMPLICATIONS AND SEQUEL/E OF DIABETES 145 

sible to drink milk or large quantities of lemonade. At the same 
time the action of the heart should be supported, either by alco- 
hol, which acts also as a food, given by mouth, or camphor (10 
per cent, solution in oil or ether), or ether injected subcuta- 
neously. Oxygen should be administered, for it often relieves 
the dyspnea. The most important remedy to administer, how- 
ever, is sodium carbonate. It should be given by mouth, by rec- 
tum, by hypodermoclysis and intravenously, in 3 to 5 per cent, 
solution in normal salt. However large the dose of soda the 
urine rarely loses its acidity, and whereas 5 gm. per diem nor- 
mally always suffice to render the urine alkaline, over 100 gm. 
may not do it in coma. A diabetic patient in coma cannot get 
too much soda. 

GANGRENE. 

It is one of the most distressing and dangerous compli- Gangrene 
cations of diabetes. When it is once fully established amputation 
of the affected member becomes necessary. Most surgeons recom- 
mend dressing the gangrenous extremity with a moist boric acid 
solution and awaiting the appearance of the line of demarcation 
before performing amputation. In a diabetic gangrene, partic- 
ularly, the amputation should be performed high up in the region 
of healthy arteries. With the appearance of gangrene the diet 
should never remain altogether carbohydrate-free. It is always 
better to allow from 50 to 100 gm. of white bread or its equiva- 
lent. Occasionally prophylactic treatment should be instituted, 
especially in old people or in alcoholics, or in individuals with 
marked arterio-sclerosis, who complain of certain premonitory 
signs like continuous pain, tingling or hyperesthesia in some 
extremity. Here everything should be done to promote the 
venous back-flow from the affected member. Hot foot-baths and 
massage should be energetically instituted, while, at the same 
time every effort should be put forward to reduce the glycosuria. 

PROPHYLACTIC AND CAUSAL TREATMENT IN DIABETES. 

A few words nmv be added in regard to prophylactic and ^ eredi t ar y 

element 
causal treatment in diabetes. In many cases of diabetes an 

hereditary element is very apparent. The disease runs in fam- 
ilies and if diabetes itself does not appear in the ancestry of a 
diabetic, then one will often discover one or several members 
of the family who suffer from obesity or gout. If several mem- 
bers of a family are diabetic, or if there is a tendency to obesity 
or gout, then all the members of such a family should be warned 
against over-indulgence in carbohydrate foods. Their urine 
should be examined at intervals of at least six months for the 
appearance of sugar. Particular care should be exercised in 
this direction in individuals of such families who are obese or 



146 



COMPLICATIONS AND SEQUELS OF DIABETES 



Test for ali- 
mentary gly- 
cosuria 



Clausal treat- 
ment 



Neurotic dia- 
betes 



Diabetes in or- 
ganic nervous 
-diseases 



are rapidly becoming obese, for in them frequently the deposit 
of fat in the tissues may almost be considered a precursor of 
diabetes; the sugar in such cases, one must assume, being con- 
verted into fat and deposited in the tissues instead of being 
wasted as sugar in the urine. 

In order to make quite sure that a tendency to diabetes is 
not developing in individuals with an hereditary tendency, the 
test for the presence or absence of an alimentary glycosuria 
may to advantage be made from time to time. This is carried 
out by giving such subjects 100 to 150 grammes of dextrose at 
one time on an empty stomach. In a normal subject no sugar 
should appear in the urine after this test; if the tolerance for 
sugar is reduced, then glycosuria will appear. This warning 
should never be neglected and as a prophylactic measure the 
carbohydrate foods should be somewhat restricted and the use 
of sugar and sweets temporarily reduced to a minimum. At the 
same time such individuals should be instructed to indulge in 
abundant muscular exercise and to live as much in the fresh 
air as possible. Very obese subjects should be submitted to a 
careful reduction cure, as described in the next section. 

Cases of this kind, in which diabetes is suspected from the 
family history and in which the test for alimentary glycosuria 
gives a positive reaction, are fortunate exceptions; fortunate, 
because at this early stage proper treatment generally quickly 
restores normal conditions and prevents the development of 
true diabetes. As a rule diabetes develops without warning or 
sugar is discovered by chance during a life insurance examina- 
tion or in the course of some ailment that calls for an analysis 
of the urine, so that an opportunity for prophylactic treat- 
ment is unfortunately rarely offered. 

Causal treatment is not very satisfactory in view of our 
ignorance of the precise nature of the disease and on account 
of the manifold character of the causes that determine its onset. 
There are certain cases of diabetes that develop on the basis 
of a neurasthenic tendency. This form, it appears to me, is 
particularly common among Jews. The sugar excretion of these 
cases is frequently increased by w T orry or emotional strain, and 
decreased by joyful emotions or success and happiness. Here 
causal treatment must clearly be directed towards the underly- 
ing neurotic taint, with the aid of certain nerve tonics and 
sedatives (see Medicament ou s Treatment, page 132) and those 
other means that are described in full in the Chapter on 
Gastric Neuroses. 

In organic disorders of the nervous system, that is, in tu- 
mors, hemorrhagic foci, cysts or other lesions in the region of 
the "glycosuric centre" in the medulla, and possibly in othet 



OBESITY 147 

areas of the brain and cord, the prognosis is dependent alto- 
gether upon the nature of the underlying lesion; and treatment 
is successful only in so far as it can remove the mechanical cause 
producing the disorder. 

Provided the lesion in the nervous system is syphilitic, or s yP hllls 
if there is a suspicion of syphilitic interstitial pancreatitis or 
hepatitis, then energetic antiluetic treatment, as discussed in 
another portion (see page 594f ), is occasionally fraught with suc- 
cess. Inasmuch as syphilis of the nervous system, the pancreas 
and the liver, as well as arterial degeneration due to syphilis, 
may all occasionally produce diabetes (the latter by producing 
secondary nutritional, i. e., degenerative, changes in the pan- 
creas, medulla, etc.), every case of diabetes giving a syphilitic 
history should be granted the full benefit of long continued and 
persistent anti-syphilitic medication. The results obtained from 
such treatment are frequently exceedingly gratifying. 

II. OBESITY. 

The reduction of obesitv is an important therapeutic task, Importance of 

reducing" 
not so much when considered in the light merely of a tribute obesity 

to the vanity of the afflicted, but chiefly when regarded as a 
necessity in order to remove an over-growth of adipose tissue 
leading to disagreeable and dangerous complications about im- 
portant organs. It will often be found that these complications 
only disappear when the fat is reduced. We see here similar 
conditions as in diabetes, for there, too, many of the complica- 
tions rapidly disappear when the sugar is reduced. Whereas 
in diabetes the causes that determine* these complications are 
chemical, in obesity they are mechanical in character. 

The organs most frequently and most seriously affected in 
obesity are the heart and arteries, the bronchi, the digestive 
apparatus, the nervous system and the skin. 

' Upon the heart is always thrown an enormous amount of ex- Complications 
cessive labor. First, because the body is heavier and locomo- ? boU f the 
tion requires more labor. Second, because a much larger vas- 
cular area than in a normal subject must be supplied, owing to 
the intricate labyrinth of new blood vessels that forms in the 
adipose tissue. Third, because the development of fat in the 
mediastinum and around and within the pericardium exercises 
mechanical pressure upon the heart and hence interferes with 
its action. Fourth, because fatty degeneration of the vessel 
walls very often occurs, with loss of elasticity and consequently p a tty deg-ener- 
an increased strain upon the heart muscle. Fifth, because owing ation of the 

b.63,rt (find 

to the development of abdominal fat the excursions of the dia- arteries 
phragm are seriously interfered with and there is a general con- 
traction of the thoracic space with a reduction of its suction 



148 



Complications 
about the re- 
spiratory ap- 
paratus 



Dyspnea 
Chronic bron- 
chitis 



action, and hence a general embarrassment of the venous circula- 
tion. Lastly, because either as a result of all this over-strain, 
or as a part phenomenon of the general obesity, fatty infiltration 
or fatty degeneration of the heart muscle itself occurs. 

As a matter of fact the affliction of the heart is probably 
the most serious consequence of obesity; for most obese subjects 
suffer from cardiopathy and die from heart failure. If, more- 
over, they should become affected with some intercurrent in- 
fectious disease, as pneumonia, typhoid fever, tuberculosis, etc., 
then the resisting powers of the heart are so slight that death 
commonly occurs from failure of the organ. 

The involvement of the heart in obesity leads to the clos- 
ing of a vicious circle; for the weak heart action produces an 
inadequate blood supply to various portions of the body with in- 
sufficient nutrition of muscular tissues and general lassitude, 
all factors that in predisposed subjects favor the development 
of obesity; on the other hand, as soon as obesity appears, it in 
its turn reacts unfavorably upon the heart. 

About the respiratory apparatus serious disorders are also 
very common. The fat in the mediastinum and the increased 
weight of the chest walls, the impediment to the downward ex- 
cursions of the diaphragm that is created by the over-growth 
of abdominal fat, all seriously interfere with the freedom of 
the lungs and the ventilation of the thorax. As a result rapid 
breathing, especially on exertion, dyspnea, and above all, chronic 
bronchial catarrh are very common in obesity. The bronchial 
catarrh is due in part also to the venous stasis that results from 
the cardiac insufficiency. The mucus is, as a rule, very tough 
and difficult to expel. The patients cough terrifically, usually 
without much relief, as expulsion of the mucus is rendered hard 
by the emphysema and the venous stasis in the lungs and by 
the difficulty of expanding the chest as a preliminary to the 
coughing effort. This condition again imposes a severe strain 
upon the heart, especially the right heart. The bronchitis in 
obesity rarely yields to the ordinary remedies, but is promptly 
bettered if the obesity is reduced and the condition of the 
heart improves. In obesity there is, therefore, also from this 
source again, danger of pulmonary infections and many of 
these cases succumb to catarrhal pneumonia, and, notably, to 
tuberculosis. There is a popular prejudice to the effect that 
obese subjects are not very susceptible to tuberculosis; if tuber- 
culous infection occurs, however, it usually goes very hard with 
fat patients, and they constitute a large proportion of the in- 
stances of so-called "galloping" consumption. 

The disorders about the digestive apparatus are manifold in 



OBESITY 149 

character. Most of them are due to the venous stasis that re- Digestive dis- 
sults either directly from the heart weakness or indirectly from orders 
portal stasis. The most common intestinal symptoms in obesity 
are hemorrhoids and constipation; both are almost invariably Hemorrhoids 
present, the former due either to the portal stasis or to gen- Constipation 
eral interference with the venous backfiow into the abdomen, 
the latter due to the pressure of the fat masses within the 
abdomen upon the bowel, causing interference with their per- 
istaltic action ; besides there is always much difficulty in volun- 
tarily raising the abdominal pressure sufficiently to promote nor- 
mal defecation. The one-sided diet with the elimination of 
much fat and carbohydrate pabulum may also have something to 
do with constipation in obesity. 

Fatty infiltration of the liver, combined with stasis and Fatty infiltra- 
later cirrhosis, is not uncommon. Cholelithiasis and dislocation liver 
of the liver are not common during the stage of obesity, but Cirrhosis 
frequently follow rapid reduction cures, owing to the fact that ^epatis 
the support of the abdominal fat is rapidly withdrawn, and 
malposition of the liver and bending or knuckling of the gall- 
ducts is produced. 

About the skin a variety of irritative disorders, complicated s . kin affec- 
by secondary infections, are frequent. They are due both to 
the friction of abnormally enlarged adjacent parts of the body 
and to the profuse sweating that most obese subjects are afflicted 
with. The sweating is attributable presumably to an effort on 
the part of the organism to get rid of surface heat by water 
evaporation from the skin, especially as normal radiation is 
interfered with on account of the thick adipose layer that con- 
ducts heat so badly. Obese subjects frequently suffer from inter- 
trigo, eczema, furunculosis, carbuncles and sudamina; besides, 
the skin often becomes torn in its lower layers leading to the 
formation of stria?, while, at the same time capillary hemor- 
rhages, venous ectases, are frequent and varicose veins in various 
parts of the body make their appearance. 

About the nervous system, finally, a great variety of func- Nervous dis- 
tional disorders, many of them of a neurasthenic type, are com- orders 
mon. Most of them are due to the inadequate blood supply to 
the brain that results from the heart weakness. Apathy and 
a phlegmatic temperament are notoriously common in obesity, phlegmatic 
These psychic attributes, combined with what is popularly in- temperament 
terpreted as a good-natured disposition, are presumably a re- 
sult of the bulk of the individual ; for, with the difficulty of 
moving about freely, and an inability to speedily carry the dic- 
tates even of an energetic will into rapid execution, habits of 
listlessness, laziness and indifference are easily . engendered, so 



150 



Obesity and 
joint affections 



The three 
forms of 
obesity- 



Diet and ex- 
ercise 



that after a time the bodily condition becomes reflected in the 
temperament. 

More serious manifestations about the nervous system are 
apoplexies, especially in patients with a weak heart and arterio- 
sclerotic arteries, who are suffering from such conditions as bron- 
chitis, constipation, etc., which call for violent straining efforts. 

I have summarized the various complicating disorders in 
obesity somewhat at length, because from a therapeutic stand- 
point it is exceedingly important to recognize the etiologic role 
of obesity in these various states. Treatment directed towards 
them symptomatically is usually futile and intelligent thera- 
peutic effort must concern itself chiefly with removing the un- 
derlying cause, namely, the obesity. I will have occasion to refer 
to this form of treatment again in the different sections when 
discussing diseases of the heart and bronchi, of the bowel and 
the liver. 

The importance of reducing obesity in a variety of chronic 
joint disorders may finally also be mentioned; for here the re- 
duction of the bulk of the patient by relieving the joints of the 
labor of supporting a large mass acts in the same way as a 
mechanical support. Thus the reduction of obesity is a par- 
ticularly grateful procedure in chronic rheumatic and gouty 
forms of arthritis. 

As in diabetes, one can conveniently distinguish three de- 
grees of obesity that have been aptly characterized by a Ger- 
man writer as the enviable, the comical and the pitiable stages. 
The first presenting itself as a pleasing rotundity: the second, 
as a jovial embonpoint of the Falstaff type; the third as a sad, 
unwieldy, and to our Caucasian tastes, disgusting deformity. 
Each of these three forms requires particular treatment. In 
the first form no attempt need be made to reduce the amount 
of fat but every effort should be put forward to prevent its 
further development, particularly if premonitory signs of com- 
plications about the thoracic or abdominal organs begin to make 
their appearance. In the second and third forms, however, it 
becomes necessary to institute more or less energetic restrictions 
with the object in view of causing a loss of fat. 

The methods at our disposal for accomplishing this purpose 
are chiefly dietetic. Second in importance is the regulation of 
the muscular exercise. These two means, singly or combined, 
usually suffice to accomplish the desired purpose, for with a 
decrease of the intake of fat-forming pabulum, and an increase 
of its destruction by exercise, the fat content of the body must 
needs dwindle. These measures may to advantage be enforced 
by certain hydro-therapeutic and medicinal means, the latter 



THE DIETETIC TREATMENT OF OBESITY 151 

finding their chief sphere of application, however, in the symp- 
tomatic treatment of the complications of obesity. ' 

THE DIETETIC TREATMENT OF OBESITY. 

Physicians until recently, and the laity to this day, have 
directed their attention chiefly to the quality or the preparation 
of the food in reducing obesity. Certain articles were said to 
form fat and others not. This idea is erroneous. Broadly speak- 
ing, carbohydrate and fat foods should be reduced, and not 
the albumens. This rule is to be observed not because albumen the food and 
"forms" less fat than carbohydrates or fats, but because the its mod e of 
reduction of the albumen below certain normal average require- 
ments, as will be explained below, is a dangerous and precarious 
procedure, whereas the fats and carbohydrates can be much re- 
duced without detriment to the individual. 

One may say, axiomatically (but with certain restrictions 
that need not be discussed in this volume),* that any article of 
food can form fat according to its caloric value (see page 114), 
that if more calories are introduced either in the form of albu- nf thp U ^/? y 
mens or of fats or of carbohydrates, than are required to main- 
tain normal nutritive equilibrium, then fat will be deposited in 
the tissues; and if less are introduced, that then the organism 
will promptly attack first its fat reserve to make up the caloric 
deficit. 

THE SCIENCE OF REDUCTION CURES. 

The initial procedure in instituting a reduction cure should 
be to determine the normal caloric requirement of the individual, 
assuming that he wen not obese. This can be done by consult- 
ing the following table on which will be found the normal aver- 
age weight for individuals of a certain height, both men and 



of the food 



women : 


(Quetelet.) 
Men. 




Women. 




Age, 


Height, 


Weight, 


Height, 


AVeight, 


Years. 


(In Meters).*-' 


(Kilo- 
grammes).*** 




(Kilo- 
grammes). 





0.5 


3.2 


0.49 


2.91 


1 


0.7 


9.45 


0.69 


8.79 


2 


0.77 


11.34 


0.78 


10.67 


3 


0.86 


12.47 


0.85 


11.79 


4 


0.92 


14.23 


0.92 


13.00 


5 


0.99 


15.77 


0.98 


14.36 


6 


1.05 


17.24 


1.10 


16.01 


7 


1.11 


19.10 


1.15 


17.54 


8 


1.16 


20.76 


1.18 


19.08 



*See my forthcoming book oil "Diseases of Metabolism." 
**1 meter— 30.37 inches, or 1 yard 3 1-3 inches (English). 
***1 kilogramme — 2 lb. 3 oz. 2 dr. (avoirdnpe.is). 



152 



THE DIETETIC TREATMENT OF OBESITY 





Men. 




Women. 




Age, 


Height, 


Weight, 


Height, 


Weight, 


Years. 


(In Meters). 


(Kilo- 
grammes). 




(Kilo- 
grammes). 


9 


1.22 


22.65 


1.19 


21.36 


10 


1.28 


24.52 


1.25 


23.52 


11 


1.33 


27.1 


1.30 


25.7 


12 


1.39 


29.8 


1.35 


29.8 


13 


1.44 


34.4 


1.40 


32.9 


14 


1.49 


38.8 


1.45 


36.7 


15 


1.55 


43.6 


1.49 


40.4 


16 


1.59 


49.7 


1.54 


43.6 


17 


1.63 


52.9 


1.56 


47.3 


18 


1.66 


57.9 


1.56 , 


51.0 


20 


1.67 


60.1 


1.57 


52.3 


25 


1.68 


62.9 


1.58 


53.3 


30 


1.68 


63.7 


1.58 


54.3 


40 


1.68 


63.7 


1.58 


55.2 


50 


1.67 


63.5 


1.53 


56.2 


60 


1.63 


62.9 


1.52 


54.3 


70 


1.62 


59.5 


1.52 


51.3 


Simplest form **J 


multiplying' this weight by 30 to 35 the approximate daily 


of reduction caloric 


requirement can b( 


i obtained, foi 


r, as shown 


on page 114, 



Three degrees 
of reduction 



Banting 1 , Oer- 
tel, Epstein, 
Hirschfeldt 
"cures." 



a normal subject requires from 30 to 35 calories per kilo a 
day to maintain adequate nutrition. Assuming that the patient 
were 1.67 meters tall, then according to the table he should 
weigh about 61 kilos and require 61X30 to 35=1830 to 2135 
calories a day. 

The diet should now be arranged in such a way, with the 
aid of the tables on page 116, that this number of calories is 
furnished, not more and not less. This constitutes the mildest 
form of underfeeding for here the caloric intake is insufficient 
only relatively, i. e., as compared to the abnormal bulk of the 
patient. If now the patient does not lose weight on a diet con- 
taining the full normal caloric requirement, then it becomes nec- 
essary to reduce the caloric intake still further. 

It is convenient to follow the plan of von Noorden and to 
arrange three degrees of reduction cures. In the first degree 
the caloric requirements are reduced only to four-fifths of the 
normal, in the second to three-fifths and in the third to two- 
fifths. Calculating this for an individual, e. g., requiring 2500 
calories as the normal, the first degree calls for the administra- 
tion of foods possessing a caloric value of about four-fifths of 
2,500, or 2,000, the second of three-fifths of 2,500, or about 1,500, 
and the third of about two-fifths of 2,500, or about 1,000 calories. 
The popular diets of Banting, Oertel, Epstein, Hirschfeldt and 
others possess a caloric value lying between 1,100 and 1,600 only; 
they are consequently reduction cures of the third degree and, 



THE DIETETIC TREATMENT OF OBESITY 153 

as will be presently shown, usually far more severe than is safe 
or necessary. 

The rapidity with which fat is lost in these three degrees of The first 
reduction cures varies. In the first degree the loss is usually de § Tee 
very slow, the patients rarely losing more than two or three 
pounds a month; and even this slight reduction can only be 
accomplished if they indulge at the same time in considerable 
physical exercise. The four-fifths diet is useful chiefly in pre- 
venting the further increase of fat in subjects who are showing 
a tendency to obesity. It is eminently suitable for continued use 
and does not require any great sacrifice on the part of the pa- 
tient. It is hardly ever necessary to calculate the caloric value 
carefully in this light form, all one has to do is to allow less 
meats, to reduce the amount of fat and starchy and sweet foods 
somewhat, to restrict or forbid alcoholic beverages, to give 
"filling" foods of small caloric value (see page 116) in abund- 
ance, to restrict the liquid intake to one to one and one-fourth 
litres of fluid a day, and to order abundant physical exercise. 

The second degree is also particularly useful for continued The second 
use. It should be adopted, first, for very strong and very fat de §" ree 
subjects who want to get rid of surplus fat and can safely in- 
dulge in very active physical exercise; second, for individuals 
who not only are fat but in whom complicating disorders about 
the heart, arteries, bronchi or digestive apparatus render it im- 
possible to "work off" fat by exercise; here the necessary reduc- 
tion of the fat must be brought about, in the beginning and un- 
til the complications improve or disappear, by dietetic restric- 
tions alone; third, for fat individuals who cannot at once toler- 
ate a third degree reduction cure without developing alarming 
symptoms of weakness, particularly about the circulatory and 
muscular apparatus. In the latter class of cases the three-fifths 
reduction cure is used as a transition diet to the third degree 
and is intended to gradually accustom the patients to restric- 
tions of a more severe order to be instituted as soon as some 
fat is lost and the complications have improved. This second 
degree, too, leads only to relatively slight and slow losses of 
fat, more than six to ten pounds rarely being sacrificed a month. 

The third degree, finally, is a rapid reduction cure. It The third 
must be carefully supervised and is best carried out in an in- de £ ree 
stitution. Here we frequently find that the loss of fat is rapid 
in proportion to the obesity of the individual, showing that it 
is the surplus adipose tissue that is being sacrificed and not the 
albumin of the body. Combined with systematic exercise and 
drink restriction (see below) as much as thirty pounds a month 
can be lost with safety. A reduction cure of the third degree 



154 



THE DIETETIC TREATMENT OF OBESITY 



Danger of re- 
duction cures 
in young and 
old subjects 



The kind of 
food 



Importance 
of protecting 
the tissue al- 
bumens 



should never be carried out for indefinite periods, and six weeks 
is the longest time during which this serious restriction of the 
patient's nourishment should be allowed. In many cases the in-, 
termittent plan will have to be adopted, i. e., the patients are 
placed for four to six weeks upon the rigid plan, then for a 
month or two upon the second degree, and then back again to 
the rigid diet until the desired loss of flesh has been produced. 

It will be seen that here very similar principles are adopted 
as in the reduction of diabetic glycosuria, where, too, three de- 
grees of diabetic diet can be conveniently arranged (see page 
124). While it is true that energetic starvation often rapidly 
leads to a loss of weight greater than that which can be accom- 
plished by more gradual and more moderate means, such rapid 
reduction cures, as typified for instance by the Banting system, 
which is so popular among the laity, are rarely without" serious 
danger to the various organs that are commonly involved in ad- 
vanced degrees of obesity ; nor are the results, broadly speaking, 
permanent. 

In very young people and in very old people rapid reduction 
cures should be altogether eschewed; for in children and in 
adolescent subjects irreparable damage is often done, growth 
stunted and serious complications engendered; whereas, in old 
people, the results are usually very unsatisfactory and never 
without danger, while the effects at best are exceedingly transi- 
tory. 

THE ART OF REDUCTION CURES. 

The kind of food that should be allowed in instituting 
any reduction cure, and its mode of preparation, has been the 
subject of much controversy for many years. The greatest 
care should be exercised not to attack the albumen content of 
the body; hence it is important to give a certain amount of 
albuminous food to all cases in order that the patients may not 
be forced to consume the albumen of their proper tissues. As 
the known minimum necessary for maintaining adequate nutri- 
tion lies somewhere between 60 and 80 grammes a day, this 
amount at least should be invariably supplied. This corresponds 
to 400 to 600 grammes of lean meat (see below). No difficulty 
should be experienced in meeting this requirement. Notwith- 
standing the claims of some doctrinaires, excessive meat-feeding 
is not only unnecessary, but may be directly harmful in insti- 
tuting reduction cures. A great deal will depend upon the 
tastes and the previous habits of the patients. If they have 
not been excessive meat-eaters, there is no reason why they 
should be forced to eat much meat. If they have been abund- 



THE DIETETIC TREATMENT OF OBESITY 155 

ant meat-eaters, they may safely continue meat-eating, provided 
the intake is not so large that the total caloric value of the 
food is increased above the prescribed and calculated limit. 

The next question to decide is whether the carbohydrates Restriction of 
or the fats are to be chiefly restricted. Here, again, a very ^hydrates* 1 " 
virulent controversy has been going on for many decades. This 
is not the place to enter into a discussion of the merits or de- 
merits of the different theories advanced. From a practical 
standpoint it is best to reduce the fats and to give relatively 
large quantities of such carbohydrate foods as possess bulk; for 
the latter, as a rule, incorporate a small caloric value, while, 
at the same time, fully satisfying the patient. The idea that 
fat forms fat in the body more than carbolrydrate lias been 
shown to be erroneous; as a matter of fact, carbohydrates seem 
to be more rapidly deposited as reserve fat in the tissues than 
the fat that is eaten. 

To summarize, therefore, the diet in reduction cures should Summary 
be arranged in such a way that the individual receives an 
amount of albuminous food incorporating at least 60 to 80 
grammes of albumen. This is necessarj 7 in order to maintain 
nitrogen equilibrium and to protect the tissue albumen. The 
remaining number of calories that are to be supplied, accord- 
ing to the principles discussed above, may be vicariously furn- 
ished, either in the form of fats or carbohydrates. Of the two 
the carbohydrates, however, especially if they are voluminous, 
should be given the preference. 

The distribution of the meals is sometimes of importance. Distribution of 
The best plan is to give three meals during the day and, in meals 
addition, two or three small meals between, the latter prefer- 
ably consisting of articles like bouillon, coffee or a little fruit, 
that possess a small caloric value. They serve the purpose of 
keeping the patient comfortable, avoiding disagreeable sensa- 
tions of weakness and gastric emptiness, and, at the same time, 
preventing the patient from becoming too ravenously hungry 
at meal times and consequently from over-eating. 

One other important principle must be observed in the feed- Restriction of 
ing, viz., the liquid intake should be restricted. Nothing is 
easier than to rapidly reduce the weight of an obese subject 
by restricting the liquid intake to a minimum. This loss of 
weight becomes particularly apparent during the first four or 
five days of the cure. It is due, in the first place, to a direct 
loss of water from the tissues; in the second place, to the fact 
that an individual drinking very little water does not eat as 
much as one taking a normal amount of liquid. The restriction, Suggestion 
therefore, in the beginning is a useful procedure, more for 



156 



THE DIETETIC TREATMENT OF OBESITY 



psychic than for physiologic reasons ; for the patients when they 
notice how rapidly they are losing flesh, acquire that confidence 
in the method that is so important if they are to carry out the 
more or less disagreeable and stringent orders that must be given. 
No permanent effects, however, are obtained from this restric- 
tion of liquids, and the patients regain their weight as quickly 
as they lost it, as soon, namely, as they begin to increase water- 
drinking. Nevertheless, even in cases in which the restrictions 
are to be continued for a long time, a reduction of the total 
liquid intake to about one to one and one-half litres in the 
twenty-four hours is a useful adjuvant. It renders it easier 
for the patients to live up to their restrictions and it is also 
beneficial - in advanced cases of obesity with complications, be- 
cause it spares the heart and kidneys. In cases, finally, that 
suffer from excessive sweating, the restriction of liquids is also 
a very useful procedure to remove this disagreeable symptom. 

Alcohol Alcohol may be administered to obese subjects, provided the 

caloric value of each gramme of alcohol (1 gramme=7 calories) 
is carefully included in the calculation. It should be allowed 
particularly in cases- that have been accustomed to a little alco- 
hol all their lives ; for here withdrawal of alcohol is not only an 
unnecessary hardship, but may even constitute a source of dan- 
ger, especially if a weakened heart is suddenly robbed of its 
usual stimulus. 

A few words may not be amiss in regard to certain special 
articles of food that are of particular value in the dietetic treat- 
ment of obesity. 

In selecting meat for obese subjects lean varieties should be 
given the preference. Lean meat contains about 20 per cent, 
of albumen and 1.5 to 2.0 per cent, of fat, so that 100 grammes 
of lean meat, weighed raw, furnish about 100 calories. It is 
necessary, of course that the meat should be prepared in a very 
simple way, i. e., that it should be either stewed, roasted or 
broiled. All meats that are prepared by frying, or that are 
served as ragouts or with bread crumbs, sauces and gravies, of 
course contain incalculable amounts of fat, so that their caloric 
value may assume very large proportions. It is always best, 
therefore, to forbid the use of any but lean meats, plainly 
prepared. 

Delicacies Among the animal foods that an obese subject can eat with 

impunity are a number of delicacies that are taken only in 
small quantities and, on account of their flavor, are very agree- 
able additions to the diet ; thus according to a table published by 
von Noorden, 100 calories are contained in : 



Special ar- 
ticles of diet 



Meats 



THE DIETETIC TREATMENT OF OBESITY 157 

45 grammes of caviar. 

40 grammes of sardines. 
100 grammes of boiled lobster. 
160 grammes of crab meat. 

120 grammes of oysters (equal to about 14 to 18 
oysters of medium size). 

25 grammes of pate de foie gras. 

Cheese also serves a useful purpose; for taken even in very Cheese 
small quantities it is very filling. Thus Swiss cheese, Ameri- 
can cheese, Cheddar and Chester cheese contain about 28 per 
cent, of albumen, 30 per cent, of fat and 2 per cent, of carbohy- 
drate, and 25 grammes of these cheeses furnish about 100 cal- 
ories. 

Milk is a very useful addition to the bill of fare, provided Milk 
its caloric value and the water it contains are included in the 
calculation. 100 cc. of milk furnish about 60 calories. 
This amount can safely be allowed with tea and coffee. Butter- Buttermilk 
milk is still more useful; for 100 cc. of this beverage only con- 
tain from 40 to 45 calories, and a whole quart about 250 cal- 
ories. 

Thin soups and bouillons and beef tea are exceedingly use- Soups 
ful articles, for their caloric value is practically 0. They 
ore very filling, they taste good, and the patient eating a large 
plate of bouillon imagines that he is getting something of value. Sauces 

Rich sauces, as stated above, should be absolutely forbidden, 
because they are made of large quantities of fat, flour, eggs 
and their caloric value can hardly be calculated. Articles made 
of flour or rice, like noodles and macaroni, puddings, etc., 
should not be allowed at all in the strict reduction cures. In Articles made 
the first and second degrees, however, small quantities may be 
permitted as a relish. If they are given, each tablespoonful of 
these articles should be figured as representing about 30 cal- 
ories. 

Potatoes are also permitted, provided they are given in Potatoes 
small quantities and are either boiled or baked or mashed and 
served without butter. One hundred grammes of potatoes pre- 
pared in this way contain about 1.5 per cent, of albumen and 
18.5 per cent, of carbohydrate, and possess a nutritive value of 
approximately 80 calories. 

Among the vegetables those varieties that grow underground Miscellaneous 
as well as those that grow in pods should be forbidden or re- vege a es 
stricted, because they contain very large and varying amounts 
of carbohydrates. If they are permitted at all in the lighter 
reduction cures their caloric value should be carefully deter- 



158 



THE DIETETIC TREATMENT OF OBESITY 



Preparation of 
vegetables 



Pruit 



Bread 



Mineral 
waters 



Pvesort treat- 
ment 



mined. All the other vegetables are exceedingly useful articles 
of diet in obesity, for they possess a very small caloric value in 
proportion to their bulk and consequently fill the stomach and 
rapidly produce a sense of satiety; incidentally they act fav- 
orably upon the function of the bowel. They should be served 
only boiled in salt water, without the addition of cream, butter, 
flour, etc. If flour or fats are used in preparing vegetable dishes 
the amounts of these ingredients should be carefully weighed and 
their caloric value considered. 

Fruits of all kinds, with the exception of bananas, sweet 
grapes, figs, dates, raisins, are permitted without reserve; they, 
too, are very filling and act well upon the digestive apparatus 
and constitute a great relish without, at the same time, possess- 
ing a high caloric value. About 100 calories are contained in 
from 220 to 250 grammes of fruit. 

The use of bread is permitted in obesity, only however if the 
bread is carefully weighed and its caloric value considered. 
Here the same rules obtain as in the feeding of bread to diabet- 
ics, i. e., those varieties that are made of vegetable albumen 
(gluten breads, aleuronat bread, etc.), are particularly useful 
if they are baked so as to become fluffy and voluminous, for 
they, too, are filling without possessing a very large caloric 
value. I have already shown on page 126 how their caloric value 
is to be calculated. 

A great many mineral waters enjoy deserved popularity in 
the treatment of obesity, notably, the waters of Kissingen, Vichy, 
Homburg, Carlsbad and Marienbad. It is a futile task, how- 
ever, to attempt the reduction of obesity by the use of these 
waters alone. It is possible, of course, by producing profuse- 
watery diarrhea with the aid of these waters to cause a consid- 
erable loss of water from the tissues and hence a reduction in 
the weight of the patient. This practice is of some use for 
psychologic reasons, because the rapid loss of weight in the be- 
ginning of the treatment makes a great impression upon the 
patients and renders them more willing to follow directions later 
on. The indiscriminate use of mineral waters is, however, to 
be condemned; for if the diarrhea is allowed to persist too long 
the effect is without doubt weakening, and this practice, more- 
over, reacts unfavorably upon the blood pressure and the heart, 
especially in obesity. 

These patients do very well, as a rule, in resorts in which 
these waters are taken, but the effects are to be attributed only 
in a very small part to the drinking of the particular water, and 
much more to the careful dietetic regulations that are usually 
carried out in these watering places, and, above all, to the 



THE DIETETIC TREATMENT OF OBESITY 159 

increased muscular exercise that these patients willingly undergo 
in a resort. 

This element of muscular exercise is second in importance Muscular ex- 
only- to the regulation of the diet in obesity. It can readily be ercise 
calculated how a definite amount of muscular exercise causes 
the loss of a definite amount of fat. Oertel, Avho has studied, 
more than anybody else, the effect of graduated exercise, espe- 
cially graduated hill-climbing, upon obesity and the action of 
the heart, based his original recommendations upon definite 
calculations.* 

In Nauheim and certain other watering places the Oertel- Terrain cure 
Terrain cure is given by instructing the patients to slowly in Naunemi 
climb a series of paths that are elevated at an angle of from 
to 20 degrees ; at the same time, certain other factors are care- 
fully considered (see page 23), as the heart's action improves 
and the fat is lost, more exercise is allowed each day. In this 
way it is possible to carefully grade the exercises and remarkably 
good results are obtained from this practice. 

Other useful exercises besides walking on a level or hill- Outdoor 
climbing, are bicycle riding, rowing and a number of light s P° rts 
out-of-door games. Rowing is especially useful, for the amount 
of exercise can be carefully regulated while, at the same time, 
full expansion of the lungs with improved oxygenation is pro- 
moted. In winter rowing machines fulfill the same useful pur- 
pose. Horse-back riding enjovs very good repute as a means Horseback 

* . . riding 

of reducing obesity ; this reputation, as a German writer states, 

is deserved as far as the horse is concerned, but not the rider; 
horse-back riding stimulates the appetite more than any other 
exercise, without leading to any reduction of the body fat. 

Massage is of no value whatever in the treatment of obesity. Massage 
Von Xoorden and his pupils have shown by very careful meta- 
bolic studies that long continued massage of the whole body 
exercises no greater influence upon metabolism than opening 
and shutting one hand energetically a few times. 



♦Assuming that a man weighing GO kilogrammes ascends an eleva- 
tion each day of 100 meters, then the labor performed is equal to GOx 
100— 0.000 kilogrammeters ; as a matter of fact, much more energy is 
expended, for the external labor produced represents only about 30 per 
cent of the total energy developed ; thus such an individual in a day 
develops fully 20,000 kilogrammeters of energy. As 425 kilogrammeters 
of muscle work require 1 calorie, 20,000 kilogrammeters require 47.0G 
calories, and this amount of caloric value is furnished by 47.06-^9.3= 
5.0G of fat. It will be seen, therefore, that such an individual must con- 
sume 5.0G of body fat to raise his body 100 meters. It is immaterial, of 
course, according to the laws of the conservation of energy, whether or 
not this elevation is reached within a short time or within a long time, 
by a vertical path or by a long series of inclined paths. 



160 



THE DIETETIC TREATMENT OF OBESITY 



Hydrotherapy 



Medicinal 
treatment 



Thyroid 
therapy 



Hydro-therapeutic measures are useful for several reasons. 
Cold baths, especially when combined with, friction, cause a 
considerable loss of heat from the surfaces of the body and 
hence stimulate the organism to increased heat production with 
consumption of body fat. Hot baths act chiefly on account of 
their diaphoretic action and are synonymous in their effect with 
any other sweating procedure. The condition of the nervous 
system, of the circulatory apparatus and of the bronchi and 
the skin, must always be carefully considered when advising 
the use of hydro-therapeutic means, and the same contra-indica- 
tions to their employment in obesity exist as in any other case 
of cardio-vascular, renal or respiratory disease. ■ These contra- 
indications have been fully discussed in their appropriate places. 

The medicinal treatment of obesity is of very subordinate 
importance. The complications occasionally call for drugs, as 
described in the chapters on the heart, the arteries, the bronchi, 
the digestive organs, the nervous system. For the reduction of 
obesity only one remedy can be employed, namely, thyroid gland 
preparations. 

The use of thyroid in obesity at one time was very popular, 
and this remedy has been carefully tested for several years. Its 
effects are always uncertain, some obese subjects reacting to the 
administration of the drug by a rapid, sometimes almost alarm- 
ing, loss of flesh, others not reacting at all. The effect of the 
drug, moreover, is not permanent, for as soon as its use is dis- 
continued the patients rapidly regain the lost fat; besides, it 
is not without danger, especially when used indiscriminately by 
the laity; for the syndrome of thyroidism (see page 102) mani- 
festing itself in a variety of disagreeable symptoms about the 
nervous system and the circulatory apparatus is always to be 
dreaded. Cases are on record, moreover, in which the use of 
large doses of thyroid extract produced glycosuria, and in view 
of the fact that there is an intimate pathogenetic relationship 
between obesity and diabetes, this is particularly to be feared; 
for occasionally it has seemed that a true diabetes mellitus was 
precipitated by the use of thyroid extract. Generally speak- 
ing, the use of the drug is superfluous, because obesity can 
always be reduced if the dietetic regulations discussed in the 
preceding paragraphs are conscientiously carried out. The one 
real benefit that might occasionally accrue from the use of thy- 
roid would be to produce a rapid loss of flesh, in the beginning 
of a reduction cure, and in this way to exercise a strong sugges- 
tive effect upon the patient, thus giving him confidence in the 
efficacy of the measures employed for his relief; but even this 
suggestive effect can, as shown above, be equally well produced 



RHEUMATISM 161 

by the restriction of water drinking or by sweating without, at 
the same time, doing the patient any harm. For the dose and 
administration of thyroid gland preparations see iudex. 

III. RHEUMATISM. 

The term rheumatism is a remnant of an ancient nomencla- Nomenclature 
ture and is loosely employed to designate a great number of mor- 
bid conditions, many of them related in no way to one another. 
Used originally by the humoral pathologists to indicate the cir- 
culation of disordered humors, it was later applied to a variety 
of fleeting pains in many parts of the body, i. e., to a symptom. 
As such pains were commonly produced by exposure to cold 
and dampness, many disorders that followed such exposure were 
called rheumatic, so that the term was used in an etiologic 
sense. As the joints were commonly affected in these disorders, 
the term rheumatism was later loosely used to indicate joint 
affections in general. Finally, a "rheumatic diathesis" was con- 
structed in which there was said to be a special predisposition to 
articular involvement (" Arthritism" of the French). 

From the clinical standpoint, and also from the standpoint 
of etiology, it becomes necessary to exclude as not belonging 
at all to rheumatism : 

Fust. Acute articular rheumatism, or rheumatic fever, a Rheumatic 
disease that is without doubt infectious in character. This dis- 
order will be discussed in the Chapter on Infectious Diseases. 

Scconel. A variety of articular inflammations that are Pseud °- rneu_ 

matism 

grouped under the unfortunate name of pseudo-rheumatism, 
that are of parasitic origin and due to infection of the joints 
with certain bacteria, or to inflammation of the joint membranes 
by their toxins. To this group belong gonorrheal, pneumococ- 
cus, diphtheritic, influenza, staphylococcus and tuberculous ar- 
thritis, also the joint lesions seen in scarlatina and measles. 
These, too, will be mentioned in the sections on the different 
diseases that produce them. 

Third. The acute articular lesions of gout. These are often Rheumatic 
confounded with rheumatic lesions but are not related to them. * out 
Hence they will be discussed separately in the Chapter on Gout 
and the Uric Aciel Diathesis. 

In fact "the words 'rheumatism' and 'rheumatic' are often 
so loosely employed that they have almost forfeited all claim to 
be regarded as scientific terms." (A. E. Garrod. ) Consequently 
I do not feel justified in discussing under the title of rheuma- 
tism the great array of symptoms involving almost every organ 
of the body, chiefly the nervous system, the peri- and endocar- 
dium, the pharynx, the tonsils, the eye, the skin and the perios- 



162 



RHEUMATISM 



Muscular rheu- 
matism 



Chronic rheu- 
matism 



teum that have been included under this term, but prefer to 
discuss the "rheumatic" inflammations affecting these differ- 
ent tissues in the Sections devoted to the diseases of the various 
organs involved. On account of the great frequency and clini- 
cal importance of rheumatic myalgia, and on account of the 
popularity of the term "muscular rheumatism" employed to 
designate this disorder, a special chapter may, however, for 
practical reasons be given to the treatment of this affection. 

There remain to be discussed separately a number of varie- 
ties of "chronic rheumatism." Some of them are consecutive 
to acuta articular lesions, others have an insidious onset and run 
a chronic, usually progressive course. They all have a tend- 
ency to involve several joints, with their tendons and muscle 
sheaths at once, and to appear symmetrically, although some 
mono-articular forms are known (malum coxa3 senilis and 
pseudo-arthritis vertebralis). In all of them are found ana- 
tomic changes about the fibrous tissues and synovial membranes, 
the cartilages of the joints, with osteophyte formation and os- 
seous atrophy. To be excluded from these forms, from the 
standpoint of anatomic classification, are those varieties in 
which urate deposits are present, i. e., that are manifestly due 
to the uratic diathesis ; also the syphilitic joint lesions and those 
forms that are due to some primary disorders of the spina] 
cord (spinal arthropathies) ; finally, those forms that are due 
to chronic suppuration. 

However interesting and important it may be with respect 
to the etiology, pathological anatomy and diagnosis, to differen- 
tiate between these manifold forms of chronic rheumatism, from 
therapeutic considerations it. is unnecessary; for the treatment 
of all these varieties, notwithstanding their origin and imma- 
terial whether the disease involves the joints, the tendons or the 
muscle sheaths, singly or together, is practically the same. In- 
asmuch as, on the one hand, the same term is often used to 
designate different disorders, and, as on the other hand, many 
terms are employed by different writers synonymously, to des- 
ignate the same lesions, 1 I will not undertake in this volume 2 



( 1 ) The most common and the most popular terms employed to des- 
ignate this large and heterogenous group of morbid entities are arthritis 
or pseudo-arthritis deformans, rheumatoid arthritis and chronic articu- 
lar rheumatism. The following terms, however, are all used to desig- 
nate chronic progressive "rheumatism" of different joints not due to 
acute infections (pseudo-rheumatism and rheumatic fever). 

Goutte Asthenique Primitive (Landre Beauvais, 1800). , 

Digitorum Nodi (Heberden, 1S04). 

Nodosity of the Joints (Haygarth, 1805). 

Chronic Rheumatism of the Joints (Todd, 1843). 

Arthrite seche (Deville und Broca, 1848 und 1850). 

Rheumatisme Chronique Primitif (Charcot u. Vidal, 1853 u. 1855). 



MUSCULAR RHEUMATISM 163 

to bring order out of this chaos, especially as any classifica- 
tion, however refined and accurate it might be, would in no way 
render us more successful in the treatment of chronic rheuma- 
tism. 

It is my intention, therefore, in the following pages, under 
the heading of "Chronic Rheumatism," to discuss together the 
treatment of chronic articular, tendinous and muscular lesions 
that are either consecutive to any of the acute forms of arthritis, 
or that are due to trophic changes (spinal lesions), or that are 
of unknown etiology and run a chronic course. I am fully 
aware of the fact that this procedure must appear inexact, but 
I see myself regretfully forced into this necessity by reasons 
-*)f practical expediency, otherwise enaiess reiteration would be 
necessary. We can only hope that before long more light may 
be thrown into this obscure region. 



MUSCULAR RHEUMATISM. 

Muscular rheumatism or myalgia (lumbago, pleurodynia, Definition 
torticollis, etc.) is in all probability a neuralgia of the sensory 
nerves of the muscles involved and not an affection of the proper 
muscle structures. The term rheumatism, as explained in pre- 
vious paragraphs, is a misnomer. Uric acid has nothing whatso- 
ever to do with so-called muscular rheumatism, popular preju- 
dices to this effect to the contrary notwithstanding. In view of 
our ignorance of the real nature of myalgia and of its exact 
causes, treatment can, of necessity, be only symptomatic. 

As the disorder generally follows exposure to wet and cold Protection 
the same rules in regard to clothing and the general hygiene and^et 00 ^ 
of the patient should be observed that are mentioned in detail 
under Rhinitis and Anemia. 

An attack of muscular rheumatism can occasionally be abort- Abortion of 
ed. Upon the appearance of the pain the patient should take the attack 



Usure des Cartilages Articulaires (Cruveillier, 1858). 
Chronic Rheumatic Arthritis (Adams, 1857). 
Rheumatisme Noueux (Trousseau, 18G0). 
Arthritis deformans (Virchow, 18G9). 
Rheumatoid Arthritis (Sir A. Garrod, 1876). 
Osteoarthritis (Spencer, 1888). 
Pernicious Arthritis (Brahazon, 1896). 

Rheumatisme chronique infectieux (Chauffard und Ramon, 1896). 
Rh. chr. infectieux et diathesique (Pierre Marie). 
Rhumat. chr. progressif (Charcot, Le Gendre). 
Polyarthritis villosa und Arthritis deform. (Schueller). 
Arthritis nodosa (Schuchardt). 
Osteoarthritis deformans (Schuchardt). 
Rhum. chr. deformant (Teissier und Roque). [Pribram.] 
(2) *For a detailed discussion of this part of the subject, see my 
forthcoming book on "Diseases of Metabolism." 



164 



MUSCULAR RHEUMATISM 



Anodynes and 
anti-neuralgics 



Salicylates 
Alkalies 



a Turkish bath, or a hot bath of 100° to 105° F., followed by 
a sweat between woolen blankets; internally ten grains of Dov- 
er's powder, or five grains of quinine with five grains of salol. 
Free catharsis should be promoted by a tablespoonful of mag- 
nesium sulphate. 

If these measures fail to abort the attack, then treatment 
with anodynes and anti-neuralgics should be instituted. This 
therapy is based on the following principles: Patients with 
muscular rheumatism have a tendency to voluntarily immobilize 
the affected muscles ; they do this in order to stop the pain. 
The arrest of the movement of the muscles undoubtedly re- 
tards the healing of the attack, for reasons that we do not un- 
derstand. To discuss the numerous theories that have been 
advanced to explain this phenomenon would serve no practical 
purpose. So much we know that active movements of rheu- 
matic muscles hasten recovery. Hence it is good practice to 
artificially stop the pain by the administration of medicines 
by mouth or by local applications, for then the patients are 
enabled freely to move their muscles and in this way to promote 
restitution to normal conditions.* Internally, therefore, opiates, 
phenacetin, acetanilid, preferably combined with salicylates and 
alkalies, should be administered either singly or in combination. 
The following prescriptions I have found very useful: 



n 



Codeine, 


% gr. (0.016 


gm.) 


Phenacetin, 


3 gr. (0.18 


gm.) 


Salol, 


5 gr. (0.3 


gm.) 


M. 


or 




Extract of opium, 


% gr. (0.016 


gm.) 


Acetanilid, 


3 gr. (0.18 


gm.) 


Sodium salicylate, 






Sodium bicarbonate, 


aa 5 grs. (0.3 


gm.) 


M. 






S. One such powder 


to be taken every 


four 


hours with a full 


glass of water. 





If these remedies do not stop the pain, then it may become 
necessary to use morphine hypodermically, in quarter-grain 
doses repeated two or three times a day, and preferably injected 



*In the case of the intercostal group of muscles, however, that can- 
not be kept quiet at the patient's will, it may become necessary, pro- 
vided these remedies do not stop the pain, to artificially immobilize the 
affected area, in order to afford temporary relief, by strapping the chest 
with broad layers of adhesive plaster. 



MUSCULAR RHEUMATISM 165 

into the sore muscles; if the drug is administered in this way 
both the narcotic effect of the remedy and the mechanical effects 
of the puncture are utilized; for puncture alone of the affected 
muscles with a long sterile needle often acts marvelously in 
stopping the pain and in a sense in aborting the attack. 

In case of rheumatism of large muscles, and particularly in 
lumbago, acupuncture should be performed in the beginning 
of the attack, as a routine measure, by inserting an ordinary Acupuncture 
sterilized hat pin for four or five inches into the affected muscle 
and leaving it in place for from five to ten minutes. 

In addition to internal remedies heat is useful, applied by Local appli- 
means of hot water bags or a thermophore (see page 39), or ca 10ns 
by poultices made of flaxseed or bread, medicated with a few 
drops of the tincture of opium or tincture of belladonna. High 
degrees of heat applied by means of hot air and sand, as de- 
scribed in the next section (see page 171) are exceedingly use- 
ful, especially in rheumatism of the muscles of the legs and 
Arms. Mustard, belladonna or capsicum plasters may be used 
ocally over the affected area. Iodine may be painted over the 
sore muscles. Such measures as cupping, blistering or cauteri- 
zation of the skin over the rheumatic area are rarely necessary. 
Liniments, as chloroform liniment, or the following application, 
are also sometimes effective in relieving the pain : 

Tincture of aconite, 

Tincture of opium, of each, 2 drachms ( 4) 

Soap liniment, 3 ounces (96) 

m; 

I have never been convinced that particular dietetic regular Diet 
tions or restrictions exercise any determinable effect 
upon the course of muscular rheumatism, nor that 
the abundant drinking of plain water, or of any of 
the numerous medicated mineral waters, in any way 
shortens the attack or prevents the recurrence of mus- 
cular rheumatism. However important, therefore, the regula- 
tion of food and drink may be in gouty forms of musculo- 
articular affections, in simple so called muscular rheumatism 
the patient need not be unnecessarily burdened with dietetic 
restrictions. 

The constant galvanic current, by causing contractions of Electricity 
the affected muscles, and massage by mechanically moving the Massage 
muscles about, are useful adjuvants to the treatment. 



166 



CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS 



Prophylaxis 



Dwelling and 

general 

hygiene 



Clothing 



Diet 



CHRONIC RHEUMATISM AND RHEUMATOID 
ARTHRITIS.* 

In this disorder prophylactic treatment is occasionally ef- 
fective in preventing the development of irremedial disorders 
about the joints. It seems well established that most of the 
cases develop in individuals whose vitality is low, consequently 
it is of paramount importance to counteract ail extraneous in- 
fluences that can reduce their vital powers. If an individual, 
therefore, who comes from a rheumatic family, begins to com- 
plain of fleeting pains in muscles, tendons and joints, and tran- 
sitory stiffness of the fingers or the knees, his mode of life 
should be carefully regulated. 

Among the most important elements to be considered are 
the dwelling, the clothing and a variety of psychic factors. The 
patient should be instructed to seek a domicile that is dry, well- 
ventilated and light, for moisture and lack of sunlight undoubt- 
edly predispose to the development of the disease under dis- 
cussion. Living in a gloomy dwelling, moreover, exercises a 
depressing psychic influence, and this, as well as any other 
emotional strain or worry, should be most carefully avoided. 
The patients should, above all, be protected against exposure to 
wet weather or sudden temperature changes; consequently, it 
is often important to induce individuals whose occupation forces 
them to undergo such exposures to change their mode of liveli- 
hood. 

The clothing is, of course, of great importance. Many of 
these people are anemic and react badly to temperature changes. 
Linen or cotton should never be worn close to the body; for 
these textures favor rapid radiation of heat, become wet and 
cling to the body when the patient perspires and hence oblit- 
erate the layer of immovable air that should intervene between 
the skin and the first garment. Wool or flannel, or silk, are 
best of all for Reasons that have been fully set forth under the 
head of Anemia. If the individual is strong enough it is al- 
ways well to attempt to harden him (see Rhinitis), i. e., to render 
him less susceptible to temperature changes. 

The diet should be especially nourishing without over- 
loading the stomach. The error is frequently committed of feed- 
ing these individuals according to the principles that are 
outlined under the Uric Acid Diathesis. This is always dan- 
gerous; for underfeeding, with its inevitable result malnutri- 
tion, is very apt to follow from this practice. It is useful, there- 



*Definition see page 1G1. 



CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS 167 

fore, to appreciate that the uric acid diathesis, so-caJled, has 
nothing whatsoever to do with" chronic rheumatism. 

The patient should be instructed to drink plenty of water, Water drink- 
preferably some alkaline mineral water that possesses slightly 
laxative properties. This plan is always indicated, for, in many 
of the cases the alkalinity of the blood is slightly reduced. 

The infectious character of some varieties of chronic rheu- Treatment of 

cEL'ts.rrlis.l con™ ■ 

matism cannot be denied, consequently great care should be ditions about 

exercised in removing catarrhal conditions about the orifices t J ie o ri fi ces of 

the body 
of the body, for they undoubtedly constitute an open port of 

entry for any micro-organisms that might be incriminated with 
producing the disorder. Inasmuch as women seem to be par- 
ticularly liable to chronic rheumatism, special care should be 
bestowed upon diseased conditions in the female sexual appa- 
ratus. 

The disease occasionally starts in with more or less acute Treatment of 
arthritic manifestations, or acute manifestations appear as exa- cations** 106 *" 
cerbations during the chronic course of the disease. Whenever 
the joints are acutely affected the patients should be put to 
bed on a restricted diet consisting largely of milk, alkaline wa- 
ters and some fresh fruits or vegetables, and the joints should be 
immobilized. Great care, however, should be exercised not to 
immobilize the joints too completely or for too long a time; immobiliza- 
for otherwise, irremediable adhesions and ankylosis may form, tion of the 
The chief object of the temporary immobilization is to reduce m S 
the pain by preventing contact and friction between the in- 
flamed, opposing structures within the joints. Permanent ex- 
tension has also been recommended. It acts beneficially by 
causing relaxation of the muscles and tendons, thus separating Ext ension 
the condyles and again preventing friction and pressure upon 
the joint cartilages. 

In order to reduce the swelling and stop the pain linen Moist dressing- 
bandages dipped in salt water may be applied. The bandages 
need not be changed every day but may remain in place for 
three or four days in succession, provided they are kept moist 
during all this time. The application of bandages moistened 
with 2 per cent, carbolic acid was formerly very popular, but 
a number of cases of gangrene from this source have been re- 
ported, so that this practice must be considered dangerous. A 
20 per cent, alcoholic solution of salicylic acid with a few drops 
of chloroform occasionally aids greatly in relieving the pain. 
Very good formulae for local applications of this kind are the cations 
following: 



168 



CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS 



Injections into 
the joint 



Ointments 



Salicylic acid, 
Alcohol, 
Castor oil, 
M. 



10 gm. 
50 cc. 

100 cc. 



A teaspoonful of this mixture is rubbed into the joint and 
the member then covered with silk or rubber and wrapped in 
cotton or flannel. 

Or an ointment may be applied, consisting of: 



I> 



Salicylic acid. 

Oil of terebinth, 

Lanolin, 

Paraffin, 

M. 



10 gm. 

10 cc. 
30 gm. 
50 gm. 



Or a medicated collodion may be painted upon the joint, pre- 
pared as follows : 



i? 



Methyl salicylate, 
Spirits of menthol, 
Elastic collodion, 
M. 



10 cc. 
5 cc. 
5 cc. 



One of the most popular preparations, finally, is guaiacol 
mixed with equal parts of glycerin, or with the tincture of 
iodine, in the proportion of one part of guaiacol to six parts of 
the tincture of iodine. 

Injections into the joint of iodoform emulsions of guaiacol 
have also been used; the formula recommended being: 



3 



Iodoform powder, 

Glycerin, 

Guaiacol, 

M. 



o gm. 

60 to 100 cc. 
20 drops 



In case the pain about the joints is very violent, then opium 
or belladonna ointments or chloroform liniments must be ap- 
plied, or hypodermics of morphine must even be administered. 
Counter-irritation with iodine frequently relieves. If there is 
very much swelling, then paracentesis of the joint, followed 
by the injection of the above iodoform-guaiacol preparation may 
be practised. 



CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS 169 

For internal use innumerable remedies have been recom- internal medi- 
mended, but none of them has fully vindicated the claims to catlon 
real efficacy in this disease. Guaiacol preparations should al- 
ways be tried. The carbonate of guaiacol is better than pure Guaiacol 
guaiacol as it is less irritating to the stomach and kidneys. 
The carbonate should be given in doses of five to fifteen grains 
{0.3 to 1 gm.) three or four times a day. Next in popularity Beta-Naphthol 
to guaiacol carbonate is beta-naphthol. Salicylic acid prepara- 
tions are of subordinate value in the treatment of chronic rheu- Salicylates 
matism. In view of the difficulty, however, of distinguishing 
clinically between the various forms of sub-acute rheumatism, 
it is often worth while to give salicylate preparations, either in 
the form of salol five to ten grains (0.03 to 0.65 gm.) three or 
four times a day, or as aspirin in the same doses. The so-called Salol 
.alkaline-quinine treatment, that is, the combination of quinine As P erm 
two to five grains (0.1 to 0.3 gm.) and sodium carbonate five to 
ten grains (0.3 to 0.6 gm.) may also be employed, if all other Alkaline- 
measures fail, for occasionally good results are seen from this nient 
medication. 

As soon as the acute and sub-acute stages are over, or if the Treatment of 

•case comes under observation for the first time with a fully de- full y devel- 
oped stage 
veloped case of chronic rheumatism, then treatment should be 

-directed almost exclusively towards promoting absorption of the 
exudates that may be present, towards preventing the forma- 
tion of ankylosis and contractures, or towards loosening the 
.ankylosis and relieving the contractures if they have already 
formed. 

In order to fulfill these objects dietetic and medicamentons 
measures are of very subordinate importance. What remedies Subordinate 
are given should be administered as general tonics, or in order ^ue-s aUC6 
to correct any anemia that may be present, or, symptomatically, 
to relieve pain or other disagreeable local symptoms; thus 
strychnine, quinine, iron, arsenic and occasionally guaiacol car- 
bonate, salol, beta-naphthol, and the other remedies that have 
been enumerated above when discussing the drug treatment of 
the acute and sub-acute arthritic manifestations of chronic rheu- 
matism, may all be utilized. The chief reliance, however, should 
be placed upon external measures. Neither diet nor drugs can Value of ex- 
accomplish much in this disease. Local external treatment can te ^ na l appli- 

^ cations 

accomplish everything that one can reasonably expect to see 

brought about. 

Heat in various forms must be applied to the affected joints. Heat 
Hot baths, plain or medicated, mud baths, sand baths, steam 
baths, sun baths, hot air baths, may all be used. All of these 
baths act by accelerating the circulation of lymph and blood in 



170 CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS 



Besort and 
institution 
treatment 



Extravagant 
claims of pro- 
moters of re- 
sorts and 
waters 



the diseased joints, and hence promoting absorption of liquid,. 
semi-solid or solid exudates that may have formed., 

The temperature of the bath and the length of time during 
which the hot applications are to be made vary in each individual 
case and no fixed rules can be formulated. One cardinal ride 
should always be observed, however, viz., that, in the beginning 
of the treatment, very high temperature should never be em- 
ployed. If the individual is suffering from nervous disorders 
or from disturbances about the circulatory apparatus, then any 
bath treatment should be begun with great care and under care- 
ful supervision of the nervous reaction, the blood pressure and 
the condition of the heart and arteries. 

Inasmuch as the bath treatment must be carried out con- 
sistently for long periods of time, sometimes for months, before- 
very appreciable effects become noticeable, and as proper facili- 
ties for this treatment are only with difficulty procured at home,, 
it is usually necessary to have such patients undergo their bath 
cure in certain watering places or institutions that are espe- 
cially equipped for these treatments. The number of these re- 
sorts is legion and in selecting an institution or a watering place 
one should be governed by the circumstances of the patient, the 
time at his disposal, and many other extraneous factors that 
need not be enumerated. The chemical composition of the water 
at different resorts has very little to do with the good effects of 
these waters, nor is there anything to indicate that the addition 
of various medicinal substances as pine needles, turpentine, car- 
bonate of soda or potash, sulphid of potassium, arsenate of soda,, 
formic acid, etc., to the bath water exercises any specific effect 
upon the disease process that could not be obtained by the use 
of plain hot water. The addition of salt and other slightly irri- 
tating ingredients to the water may enforce the action of the 
heat, inasmuch as they produce increased hyperemia of the skin 
and hence more active and prolonged dilatation of the superfi- 
cial capillaries, with a correspondingly increased blood and 
lymph flow through the underlying joint structures. The slight 
advantage accruing from this effect is almost negligible, how- 
ever, so that the extravagant claims advanced by the promoters 
of different resorts and waters in this country and abroad, in 
regard to the wonderful efficacy of their particular spring in 
curing chronic rheumatism, may be dismissed without further 
comment. It all depends upon the regime at these different 
places, the facilities for securing proper massage and the method, 
of applying the hot water, but not upon the chemistry of the 
waters used. 



CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS 171 

A very convenient method of applying high degrees of tern- M ^d baths 
perature to the affected joints is by the aid of mud baths, for 
the mud particles irritate the skin and also exercise pressure 
upon the affected joint, in both these ways enforcing the action 
of the heat and promoting more rapid absorption of the patho- 
logic exudates. Here, again, it is the heat and the physical prop- 
erties of the mud and not the chemical constituents it may con- 
tain that exercise the good effects. 

For domestic application sand baths are exceedingly useful, Sand baths 
for very high temperature can be applied with the aid of sand. 
The hot sand (up to 150° F.) may be filled into little linen sacks 
and applied to the joints; in this way the benefits of both pres- 
sure and heat are obtained. The length of time during which 
the application is made varies according to the sensations of the 
patient. If the finger joints alone are involved it is a very useful 
plan to have the patient put on a cotton glove and immerse his 
hand in the sand, holding it there for fifteen minutes to an 
hour at a time, several times a day. 

The most effective way of applying heat, and the one that Hot air 
permits the use of the highest temperature, is by means of hot 
air. Special apparatus of different makes are on the market 
which enable the patients to carry out this treatment at home. 
Temperature as high as 300 to even 400 degrees F. can be borne 
without discomfort. Dry heat used in such an apparatus makes 
it possible to treat one joint at a time while the rest of the body 
is protected from the heat; this prevents disagreeable and dan- 
gerous phenomena about the nervous and circulatory apparatus. 

Sun baths and electric light baths are also employed in cer- Sun baths 
tain institutions and occasionally fulfill a useful purpose. Here, Electric haths 
again, the heat is the active agent and not, as far as we know, 
the chemical rays of the light. 

In some institutions the mechanical effect produced by a Douches 
stream of hot water directed against the joints is utilized to 
advantage to promote the circulation in the joint and to en- 
force the effect of the h^at. One of the best plans is the so- 
called "Scotch douche." Here the temperature of the stream 
of water which is directed against the affected joint with con- 
siderable force is rapidly changed from hot to cold and back 
again, and a very marked effect is generally produced in this 
way. 

A method that has recently come into deserved popularity Bier's method 
is the production of passive hyperemia in the affected joint. of passive 
This is the so-called Bier method. In order to produce passive 
hyperemia a bandage is wrapped around the limb above the 



172 CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS 



Massage and 
movements 



Electricity- 



Orthopedic and 
surgical treat 
ment 



Reduction of 
obesity 



joint. It is applied so tightly that the region about the joint 
becomes bluish-red in color and swollen. The application of the 
bandage should never produce pain in the affected articulations. 
Occasionally a little throbbing is complained of in the begin- 
ning, but even this disagreeable sensation should disappear 
within a short time. The constriction should at first be continued 
for several hours at a time, later for all day ; still later, the band- 
age is applied only during the night. No harm has ever been 
known to follow this method of treatment and some of the re- 
sults reported are exceedingly satisfactory, so that it certainly 
deserves extended trial. 

The application of heat by any of the means mentioned 
above can usually be supplemented to advantage by proper mas- 
sage and by active and passive movements of the affected joints. 
Here, too, the improvement of the circulation that follows the 
massage aids in the absorption of the pathologic exudates. Inas- 
much as this treatment should be performed by a skilled opera- 
tor it is needless to discuss the technique of massage. 

Electricity has been used in many cases of chronic rheuma- 
tism with good results, either alone or combined with heat and 
mechanical treatment. The electric current undoubtedly exer- 
cises a distinct effect upon the circulation in the skin and the 
underlying parts, and may, in this way, aid in promoting a more 
rapid flow of lymph and blood through the affected area. This 
method of treatment, too, should be carried out by an expert, 
otherwise it is usually futile. The faradic brush and the sol- 
enoid current are particularly recommended. Recently good re- 
sults have also been reported from high frequency currents, 
but this question is still in abeyance. 

In the later stages of the disease when ankylosis and deformi- 
ties have occurred, orthopedic and surgical treatment often be- 
comes necessary. In this connection the importance of reducing 
obesity in sufferers from chronic rheumatism of the joints may 
again be referred to (see page 150) ; for the reduction of the 
weight of the person of necessity relieves the joints of much 
pressure and saves them the labor of supporting a huge bulk; 
hence a reduction cure acts in the same sense as the mechanical 
supports that are given these patients by orthopedic surgeons. 
The various surgical procedures that have to be instituted in 
deformed cases cannot be discussed within the compass of this 
book. 



GOUT AND THE URIC ACID DIATHESIS 173 



IV. GOUT AND THE URIC ACID DIATHESIS.* 

Of the primary causes of the uric acid diathesis we know introductory- 
nothing. Theoretically, I place myself without equivocation Th ® principles 
upon the neuro-humoral viewpoint so ably denned by Duck- treatment of 
worth in the following words: "It is incumbent, I believe, to !? e t £ ri ? acld 
invoke not only a chemical and a physical basis for gouty dis- The neurosal 
ease, but to include also in a comprehensive review the marked e emen 
determining influence of the nervous factor in the problem." 

The neurosal element is vague and intangible, essentially 
hereditary and probably not remedial in one generation. The 
perversions of the uric acid chemism on the other hand are 
more definite and are amenable to considerable modification and 
to correction by treatment. 

There is immense confusion in this field. This may be due 
to the fact that the course of typical gout is per se irregular 
and subject to fluctuations, and that atypical gout* presents 
so protean a syndrome of functional disorders, involving almost 
every organ, that the doors are thown wide open to subjective 
misinterpretation. 

In seeking for a basis of treatment the fundamental per- 
versions characteristic of the uric acid diathesis must be de- 
termined. They are the following : 

1. The uric acid of the blood is increased. 

2. Crystalline deposits of sodium urate are found in cer- 
tain necrotic tissues. 

The former factor alone, however, by no means constitutes The increase 

the essential element of the so-called uric acid diathesis, for in ? f S5 1C , ? cld , 

' m the blood 

several diseases, notably leukemia, the circulating and excremen- 

titious uric acid may be increased immensely without ever pro- 
ducing any of the symptoms or lesions of gout or goutiness. 
It is safe, on the other hand, never to include a case under the 
category of the uric acid diathesis unless the uric acid of the 
blood is increased. 

The increase of uric acid in the blood may be due to: (1) 
Increased formation of uric acid. (2) Decreased destruction 
of uric acid. (3) Retention of uric acid; or to several of these 
factors combined. 

The analytical formation of uric acid, i. e., the genesis uric acid de- 
of uric acid from the disassimilation of more complex com- rived from 
pounds, is the common mode of formation in man. The old view 
is that uric acid is an oxidation product of albumin and an inter- 



*Synonyms: Lithemia ; Uricheniia ; Atypical, irregular, incomplete 
or abarticular Gout. 



174 



GOUT AND THE URIC ACID DIATHESIS 



Endogenous 
and exogenous 
uric acid 



Transforma- 
tion of uric 
acid 



Retention of 
uric acid 



mediary product in the formation of urea; the new view is that 
uric acid is a specific metabolic product of a special kind of 
albumin, viz., nuclein. 

Nucleins are the chief constituents of all cell nuclei and 
are hence contained in many articles of food and also in the 
tissues of our own body; uric acid may therefore be derived 
from either. As a matter of fact, the administration of nuclein 
or nuclein-containing foods by the mouth is followed by an in- 
crease of the uric acid excretion in the urine. On the other 
hand, a subject fed for a long time on a diet containing no nu- 
cleins (see below), or a subject after a prolonged period of 
fasting, still excretes appreciable quantities of uric acid. In the 
former instance the urinary uric acid was derived from the 
food nucleins; in the latter the excreted uric acid was derived 
from the tissue nucleins. 

The formation of uric acid from the food nucleins we can 
control; the formation of uric acid from our tissue nucleins we 
cannot control. Whereas the former factor is constant and 
independent of the individual, in the sense, namely, that a 
definite quantity of food nuclein invariably leads to the excre- 
tion of a definite and calculable quantity of uric a^id, the lat- 
ter factor is inconstant, varies in different individuals, and 
cannot be calculated in advance, 

The theory has been advanced, and has been supported by 
some evidence, that in subjects suffering from the uric acid 
diathesis the individual catabolism of nucleins is high; the ad- 
herents of this view consider the diathesis a "nucleolytic auto- 
intoxication" — which proposition it is difficult to prove. 

Uric acid is normally in part destroyed or transformed in 
the mammalian organism. Extracts made from liver, muscle 
and kidney in certain lower animals possess the power of con- 
verting uric acid into more highly oxidized and more soluble 
nitrogenous bodies. The author has shown that the same ap- 
plies to human liver, kidney, muscle, and blood.* 

We also know that only a portion of the calculated amount 
of uric acid is excreted after feeding with nucleins or uric acid, 
and that a part of the nitrogen appears in the urine in other 
forms. I am inclined to believe that non-destruction is a more 
prolific cause of uric acid accumulation than over-production. 

Whether or not uric acid is retained in the uric acid diathe- 
sis cannot, I believe be definitely ascertained until we 
gain more comprehensive data in regard to the uric acid ex- 
cretion before, during, and after attacks of gout, and in re- 



* Medical Record, 1903. 



GOUT AND THE URIC ACID DIATHESIS 175 

gard to the average uric acid excretion in those cases that never 
progress to the stage of gouty seizures. 

We have only recently learned to understand the influence The effect of 
■of diet on the uric acid excretion, and above all the influence a ^ c ^ id ® x _ 
-of the food nucleins on this function. It is clear that uric cretion 
acid determinations are of value only if the patient is kept on 
a diet free from nucleins during the time of observation, or 
if at least the exact nuclein content of the food is known; in 
•addition, the individual (endogenous) uric acid excretion must 
be known. Failure to comply with these fundamental postu- 
lates must be made responsible for the colossal confusion obtain- 
ing in regard to the plus or minus excretion of uric acid in 
the disease. 

In that small minority of cases of gout in which there is 
distinct granular atrophy of the kidneys some retention may 
occur. I am also inclined to believe that renal insufficiency ob- 
tains in a much larger proportion of gouty cases than is usu- 
ally assumed. I refer to those patients in whom we find in- 
creased arterial pressure with an accentuated second aortic 
•sound and signs of cardiac hypertrophy, together with certain 
retinal changes, nitrogen retention without increase of bodily 
weight, and other evidences of renal inadequacy; these cases 
appear to me to be cases of "latent" nephritis, and the absence 
of albumin from the urine does not necessarily militate against 
this diagnosis. 

Urate deposits are a characteristic finding in the uric acid Urate deposits 
diathesis, even though cases of gout occur in which no urate 
deposits are found post-mortem, and though urate deposits are 
occasionally discovered on autopsy without a history of gouty 
seizures during life. 

It appears that urate concretions can only occur if the 
blood contains an excess of uric acid in solution; the reverse, 
is not true, for in many other states (leukemia, pneumonia, lead 
nephritis, etc.) in which the blood contains abnormal quan- 
tities of uric acid no concretions develop. 

Definite factors must therefore be operative in the uric acid Tlie factors de- 
diathesis that not only favor the deposit of urates, but also de- ura te deposits 
termine certain definite points of predilection for the precipita- 
tion of sodium urate crystals. These locations are the joints, 
the tendon sheaths, the muscle fascia?, the kidneys, the external 
■ear and the bone-marrow. 

These factors must necessarily be local. It is very prob- 
able that the poor vascularization of the particular parts can 
largely be made responsible for the deposit of concretions in 
these special places. 



176 



GOUT AND THE URIC ACID DIATHESIS 



Blood alka- 
linity 



Proportion of 
salts 



Necrosis in 
the vicinity of 
urate con- 
cretions 



General con- 
siderations re- 
lative to 
treatment 
based on the 
above prin- 
ciples 



Chief indica- 
tions for 
treatment 



Much has been written in regard to the influence of reduced 
alkalinity of the blood. It does not appear, however, from ex- 
act determinations that the alkalinity of the blood is abnor- 
mally low in the uric acid diathesis. 

Changes in the relative proportion of salts (chiefly mono- 
and di-sodium phosphate) in solution in the serum are a much 
more important factor. If several salts are present in solu- 
tion the more soluble salt will precipitate the less soluble one even 
if the solution is not saturated with the latter. Given, there- 
fore, an increase of urates in the blood, with local stasis of 
blood and lymph, then a slow interchange between two relatively 
concentrated solutions occurs, and precipitation of the least 
soluble salts, the urates, obtains. 

Senile cartilages are relatively rich in salts, and the circu- 
lation in these tissues is particularly poor; hence possibly the- 
tendency of older subjects to uratic deposits in the joints. 

The significance of the necrosis found in the vicinity of urate 
concretions is still obscure. Either the urates produce the* 
necrosis or the necrosis is the primary event and prepares a 
suitable nidus for the secondary deposit of urates; the cause- 
of the necrosis in the latter event would remain unexplained; 
it may be tropho-neurotic or may be due to the action of the 
alloxuric bases, chemical congeners of uric acid. 

As the primary cause of the uric acid diathesis is unknown 
and as the neurosal element that enters into its pathogenesis 
is intangible, we are limited in our treatment to a correction of 
the perversions of the uric acid economy that we have outlined 
above. 

We find ourselves here in a similar position as in the treat- 
ment of diabetes and obesity, for in these diseases, too, we are 
limited in our endeavors to the removal of excessive sugar and 
fat and to a correction of the secondary disorders that follow 
the abnormal accumulation of these products. Unfortunately, 
we have in the uric acid diathesis no such definite index of the 
progress of the disease and the success of our treatment, as the 
disappearance of sugar from the urine or changes in the con- 
tour of the patient. The two chief indications for treatment 
are: 

1. To prevent the increase of uric acid in the blood; this 
accomplished the precipitation of urates as we have seen is 
rendered difficult. 

2. To promote the solubility of uric acid in the blood; in 
this way its precipitation may also be prevented. 

As the accumulation of uric acid may be due to increased 
formation, decreased destruction, or retention, treatment should 



GOUT AND THE URIC ACID DIATHESIS 177 

he directed towards reducing the production of uric acid, in- 
creasing its destruction, and accelerating its elimination. 

To reduce the production of uric acid is one of the most 
important, and at the same time one of the most feasible, tasks 
of dietetic treatment. We know that the uric acid is chiefly Limited use of 
formed from disintegrating cell nuclei and that the restriction ^" c fo^g" orm ~ 
of articles of food containing many cell nuclei or nuclein or 
uric acid, or its chemical congeners, the alloxuric bases (purin 
bodies), must needs decrease the formation of uric acid. And 
even should it be shown that the accumulation of uric acid is 
due to retention or non-destruction, and not to over-production, 
the limited use of uric acid-forming foods must nevertheless 
be considered altogether rational. 

We know too little of the normal mechanism of uric acid The destruc- 
destruction to enable us satisfactorily to regulate this process. ™^ ° uric 
What means we possess to accomplish this end are not dietetic. 
The withdrawal of articles of food that are more readily oxi- 
dized in the body than uric acid was at one time considered to 
be good practice, for it was argued that in this way the oxidiz- 
ing powers of the organism would not be directed toward 
a destruction of these articles, but to the destruction of accumu- 
lating uric acid instead. Since it has been shown, however, that 
uric acid is not destroyed by a proper process of combustion, 
but by a more delicate process of intracellular disassimilation 
(probably fermentative in character), this argument has been 
rendered altogether invalid. 

Certain dietetic regulations can finally directly and in- Elimination 
directly aid in the elmination of uric acid; directly, by exer- of uric acldL 
cising an effect on the circulation and the renal excretion; in- 
directly, by sparing the heart and kidneys and enabling them 
to perform their functions in a normal manner. As the latter 
organs are frequently involved in the uric acid diathesis, it is 
particularly important that the diet should contain nothing that 
can injure them. 

The following considerations, therefore, based on the prin- The diet 
ciples just predicated should govern the selection of the diet 
in the uric acid diathesis. 

There is much disagreement and misunderstanding in regard Meat 
to the use of meat. One group of extremists interdicts the 
use of meats altogether; another makes artificial distinction be- 
tween dark and red meats; and a third insists on a diet con- 
sisting almost exclusively of red meat ("Salisbury diet"). In "Salisbury''" 
this country the red and dark meat fad is particularly rampant. 
I see the matter as follows: The use of a moderate amount of 



178 



GOUT AND THE URIC ACID DIATHESIS 



Red and dark 
meats 



Nuclein con- 
taining foods 

Internal or- 
gans 

Meat extracts 
Hed meats 
Towl 



Mode of prep- 
aration 



Dangers of 
meat restrro- 
'"'on 



meat is not only permissible but necessary. Some care must 
be exercised in selecting the kind of meat and in determining 
its quantity and its mode of preparation. 

The administration of nuclein or extractives (uric acid and 
the pur in bases) should be reduced; hence all meats containing 
many cell nuclei, i. e., all internal organs (liver, kidneys, sweet- 
breads, brain, thymus) should be rigorously excluded. All 
meat extracts, broths, sauces, and gravies contain the extractives 
and are consequently bad. Raw meats, smoked and cured meats, 
sausage, etc., because they still contain the extractives, should 
also be limited. 

To exclude the flesh of fowl because birds produce more 
uric acid than mammals is based on the erroneous conclusion 
that consequently their muscles are also particularly rich in 
uric acid. There is no reason to exclude poultry. 

It has also been shown by exact analyses that there is no 
difference in regard to their uric acid content between the dark 
and the white meat of birds. This distinction is therefore also 
unnecessary. 

Boiled meat is better than roast or fried meat, because the 
extractives have been removed from the former. Some writers 
maintain that the quantities of extractives introduced with 
meat are so small that they cannot possibly exercise an appre- 
ciable effect; there is, however, some evidence to show that these 
bodies, administered in small quantities for a long time, may 
exercise a cumulative effect. It is safer, therefore, to adhere 
to the foregoing rules until evidence to the contrary is forth- 
coming. 

We are unable, of course, to directly control the nuclein 
economy of the organism proper by restricting the use of nu- 
cleins, for the body is capable of building up its tissue-nucleins 
from any proteid- and phosphorus-containing pabulum. We 
know, for instance, that whole peoples live on a vegetable diet 
free from nucleins; (these by the way are remarkably free from 
gout!). 

The albumin of the meat exercises no direct effect on the 
excretion of uric acid and may therefore be considered an essen- 
tially indifferent constituent of flesh as far as the uric acid 
economy is concerned. The quantity of meat should, however, 
be limited, although not reduced too much. The organism re- 
quires a definite quantity of nitrogenous material, and while 
it is possible to supply all the nitrogen required in articles of 
food other than meat, this procedure necessitates feeding the 
patient with large quantities of bulky material leaving much 
residue and taxing the digestive apparatus very severely. It is 



GOUT AND THE URIC ACID DIATHESIS 179 

more natural and more rational to supply a portion of the 
nitrogen in meat, especially as the withdrawal of meat consti- 
tutes a great hardship to many patients and it would be unneces- 
sarily cruel to stop its use. One pound of meat, moreover, 
contains as much nitrogen as several pounds of most other nitro- 
genous articles of food. 

Unless the caloric value of the diet is carefully calculated 
there is always danger of under-feeding the patients when meat 
is withdrawn. This is a dangerous possibility, for it favors 
the development of gouty cachexia, lowers the tone, and there- 
with reduces the activity of the oxygenation powers of the body. 
If nitrogen is deficient the organism, moreover, compensates for 
this deficiency by increasing catabolism of its own (nuclein- 
containing) tissues. 

On the other hand, too much meat is certainly bad, for, in Dangers of too 
the first place, meat produces a distinct digestion leucocytosis, much meat 
followed by the disintegration of leucocytic nuclei; in the sec- 
ond place, meat reduces the alkalinity of the blood owing to 
the sulphur and phosphorus it contains, for these elements, as 
we have seen, are oxidized to sulphuric and phosphoric acids, 
and as the bases (potassium, sodium, calcium, and magnesium) 
liberated from the meat at the same time are incapable of com- 
pletely neutralizing these acids, acidulation of the bodily fluids 
occurs (corned beef is particularly bad in this respect because 
all the basic salts are leached out in its manufacture and replac- 
ed by neutral sodium chloride) ; in the third place, meat taxes 
the eliminatory powers of the kidneys very much and these or- 
gans must be spared and protected in the uric acid diathesis. 

Eggs in moderation may be permitted. True, the yolk of Eggs 
egg contains abundant nuclein (vitellin), but this nuclein is 
different chemically from the nucleins of meat and cannot split 
off uric acid. Nevertheless, I restrict the use of yolk of egg. 
The white of the egg exercises no effect on the uric acid excre- 
tion even when given in large quantities; of course, it, too, like 
meat albumin, can reduce the blood alkalinity. Where it is 
well borne, it is, however, a very convenient form in which to 
supply nitrogen. 

An exclusive milk diet, as advised by some, is always bad, Milk 
particularly in old people; for the ingestion of large quantities 
of water incident to abundant milk drinking must needs over- 
tax the heart, the arteries, and the kidneys (see page 208 f). Milk 
as an addition to a mixed diet is good if it can be borne; here 
we must individualize. The nucleins it contains are paranu- 
cleus and do not produce uric acid. Milk slightly reduces the 



180 



GOUT AND THE URIC ACID DIATHESIS 



alkalinity of the blood, owing possibly to the generation of lac- 
tic acid and to the oxidation of its proteids. 

All these theoretical disadvantages are, however, over- 
compensated by its highly nutritious character and its powers 
to stimulate diuresis. 
Cheese In the manufacture of cheese the basic alkali salts contained 

in the milk are dissolved in the whey ; hence cheese is poor in 
these salts. The same objections can therefore be formulated 
against its use as against corned beef (see above), viz., that 
it acidulates the blood owing to the formation and incomplete 
neutralization of sulphuric and phosphoric acids; in addi- 
tion, the free fatty acids that cheese contains may enforce this 
effect. As a matter of fact the urinary acidity increases after 
a cheese diet. Empirically, cheese has been known to precipi- 
tate gouty attacks, and in certain regions of Germany where 
much cheese is eaten urinary calculi are said to be very fre- 
quent. I consequently usually exclude cheese from the dietary, 
although there is no compelling scientific reason for doing so. 
Fats It has been argued that fat should be omitted from the diet 

in uratic cases because it is so readily oxidized and hence pre- 
vents the oxidation of the nucleins. Withdrawal of fat does 
not, however, exercise any effect on nuclein catabolism nor on 
uric acid excretion. Excessive feeding, with fat has, on the 
other hand, been known to cause an increased excretion of uric 
acid. 

Paradoxical as it may sound, fat is particularly indicated in 
those cases that are inclined to obesity; for if fat is added to 
the diet, the appetite is more rapidly appeased, the patients con- 
sequently do not eat so much, and are above all not so apt to 
gormandize. 

As uric acid patients should be instructed to take much phys- 
ical exercise, the addition of some fat to the diet is almost in- 
dispensable to maintain full nutrition. 

If, therefore, certain individual idiosyncrasies, and also 
the state of the digestive apparatus, are duly considered, there 
is no valid objection to the use of fat in moderation. 
Carbohydrates Carbohydrates exercise no appreciable effect on the uric acid 

excretion nor do they irritate the kidneys. They do, however, 
favor the development of dyspeptic disorders, because they 
readily undergo fermentation and because they are so bulky. 

As all carbohydrates are quite soluble and are easily ab- 
sorbed patients living on a carbohydrate diet are very apt to 
ingest too much nutrient. Many persons, for instance, could 
without difficulty master 1,000 grammes of carbohydrate in the 
form of bread, cake, potato, etc., a day, whereas no one would 



GOUT AND THE URIC ACID DIATHESIS 181 

be tempted to eat an equivalent quantity of fat (440 grammes) 
or of albuminous food (1,000 grammes). 

Carbohydrates, moreover, favor alimentary glycosuria and, 
indirectly, the development of diabetes and obesity, both com- 
plications that are not infrequently seen together with the uric 
acid diathesis. 

Carbohydrates should therefore be restricted. In cases com- 
plicated with diabetes or obesity they should be temporarily for- 
bidden altogether or replaced by fat. In patients suffering from 
dyspeptic complications, or in persons inclined to over-eat, their 
use should also be restricted. 

Certain of the bulbous vegetables, viz., potatoes, cabbage, Fruits and 

vegetables 
etc., contain a very large percentage of carbohydrate and very 

little proteid; as they, therefore, possess all the disadvantages 

of carbohydrate foods, and only very slight nutritive value in 

proportion to their bulk, they should be used sparingly in the 

uric acid diathesis. They are also apt to undergo fermentation 

and to produce dyspeptic disorders. 

Salads and all green vegetables, on the other hand (with 
the exception of young germinating plants, such as asparagus, 
that contain much nuclein), may be given freely. They con- 
tain relatively little carbohydrate and a large proportion of 
salts. The large residue of cellulose they leave in the digestive 
tracts stimulates peristalsis and aids in keeping the bowels open ; 
this is a desideratum in gouty cases. Celery and onions are to 
be forbidden on account of the irritating oils they contain. 

All spices and condiments should be avoided; they irritate Spices and 
the digestive tract and the kidneys and above all stimulate the con imen s 
appetite and in this way encourage over-eating. 

All fruits, either deciduous or citrous, may be permitted. 
The acid salts they contain are converted into carbonates and 
render the urine alkaline; they contain very little carbohy- 
drate. Empirically, too, we know that they act beneficially in 
the uric acid diathesis (so-called "fruit cures"). Fruit acids Fruit cures 
exercise no distinct effect on the excretion of uric acid, with 
the exception of tannic acid which seems to decrease it. 

Water should be the chief beverage. Forced water-drink- Water 
ing, however, is unnecessary, even harmful, although it is 
advised by some authors. Excessive water-drinking does not in- 
crease the excretion of uric acid; nor does increased 
diuresis by any means signify increased excretion of urinary 
solids. Water in a sense is a distinct irritant of the renal epithe- 
lium; in gouty nephritis, therefore, and in cases of beginning 
renal insufficiency water in excess may do harm. Where there 



182 



GOUT AND THE URIC ACID DIATHESIS 



Mineral waters 



Tea, coffee, 
cocoa 



Alcohol 



is much arterio-sclerosis, with a weak heart muscle, the flooding 
of the circulation with water can only be detrimental. 

On the other hand, the amount of water should not be re- 
duced too much, for we know from clinical experience that this 
practice favors the formation of urinary calculi. A uric acid 
patient should therefore drink from one to one and one-half 
litres of water a day, not much more nor less. 

It is better to order the frequent drinking of small quanti- 
ties than the drinking of large quantities at long intervals. It 
is a good plan to have the patient drink one-fourth of a litre of 
warm water immediately before going to bed; this practice 
occasionally, I believe, prevents the occurrence of nocturnal 
attacks of gout. In fact, owing to the frequency with which 
gouty seizures appear in the night, it is advisable that patients 
as a routine measure should eat a frugal evening meal and 
should drink warm water before going to bed. 

The favorable effects that are said to be derived from the 
use of numerous well advertised mineral waters are probably due 
to the water, and not to the salt in solution; the so-called uric- 
acid-sclvent virtues of many of these salts seem highly prob- 
lematical to me (see below). 

Tea, coffee, cocoa are usually considered bad. I think their 
use should be greatly restricted in uric acid cases. They contain 
certain members of the group of alloxuric bases (caffeine, 
theine, theobromine, adenine, etc.), and as these bodies are 
direct precursors of uric acid some of them are presumably in 
part converted into uric acid in the organism; at all events the 
excretion of uric acid is increased after some of these substances 
are given by the mouth. There is, moreover, some evidence to 
show that these compounds may directly irritate the kidneys 
and the circulatory apparatus, also the digestive tract. 

While excessive tea or coffee drinking is, therefore, to be 
absolutely condemned, the moderate use of thin tea or coffee is, 
I think, permissible, particularly in persons who crave these 
beverages. Tea is by all means preferable to coffee, for it stimu- 
lates diuresis and is not indigestible. In patients accustomed 
to alcohol it is also much easier to limit or stop the use of the 
latter if a little tea or coffee is allowed. 

Alcohol-drinking has always been considered one of the 
chief causes of gout. In view of the almost universal preva- 
lence of the alcohol habit, however, this proposition is difficult 
to prove. There can be no doubt that an alcoholic debauch may 
occasionally precipitate a gouty attack in a predisposed subject, 
and that sufferers from gout as a rule feel better if they abstain 



GOUT AND THE URIC ACID DIATHESIS 183 

from alcohol. Alcohol is a direct irritant of the digestive tract, 
of the circulatory apparatus, and of the kidneys. No distinct 
and uniform effect of alcohol on the excretion of uric acid has 
so far been determined, notwithstanding the fact that a verit- 
able flood of investigation has been published on this question. 
The food value of alcohol is of subordinate importance in 
goutiness, for here there is no loss of valuable pabulum in the 
urine as in diabetes. 

Alcohol, chiefly on empirical grounds, is, therefore, as a 
rule, to be forbidden. At the same time we occasionally encoun- 
ter a patient who does better if a small quantity of some alco- 
holic beverage is permitted. Champagne, sweet wines, cider, 
liqueurs, and malted liquors are to be absolutely avoided; dilute 
Rhine or Moselle wine or claret or whisky with water, all in very 
small doses, may at times be allowed. 

As in all the other dietary regulations that I have outlined, 
the previous habits of the patient, his temperament and charac- 
ter, must be carefully considered. 

It is frequently easier to enforce rigid rules in one direc- 
tion if a little latitude is allowed in another, and if certain crav- 
ings and tastes — call them abnormal — are satisfied. ''By as 
sociation with rules that cannot be obeyed, rules that can bL' 
obeyed lose their authority." 

One of the most important elements to be considered in the Exercise 
treatment of the uric acid diathesis is the regulation of physi- 
cal exercise. Broadly speaking, every sufferer from manifes- 
tations of the uric acid diathesis, especially when afflicted with 
"rheumatic" and neuralgic symptoms, should indulge in abund- 
ant but light physical exercise, carried out as much as possible 
in the fresh air. In view of the fact that many of these cases 
are of a melancholy or irascible temperament, and usually 
suffer from Irypochondriasis, the exercises should partake of the 
character of sports, i. e., they should not be monotonous but 
should amuse and stimulate the patient. Moderate horse-back 
riding, golf, swimming, fencing, tennis, bicycling, rowing are 
all useful, and during the cold months, bowling, billiards and 
similar games. In view of the tendency to uratic nephritis and 
uratic myocarditis, that is always to be considered in these cases ; 
no violent exercise should be indulged in, nor should exertion ]yi assao . e 
ever be carried to the point of fatigue. If there are nephritic 
or cardio-vascular changes, then passive and resisting exercises 
and massage become exceedingly useful. 

Baths also occupy an important place in the treatment of s a ths 
the uric acid diathesis. If it is possible the patient should be 



184 



GOUT AND THE URIC ACID DIATHESIS 



Resort treat- 
ment 



Hot bathing 



Contraindi- 
cations 



Hydrotherapy 
in general 



[Medicaments 



Complications 
and sequelae 



Hepatic insuf- 
ficiency 



Dyspepsia 



advised, for a month or so of each year, to undergo a course of 
treatment in some watering place where he can have the benefit 
of hot baths combined with massage and exercises such as those 
specified above. The careful regulation of the regime, as it is 
generally carried out in resorts, combined with rest and respite 
from daily work and worries, usually exercises a most beneficial 
effect upon these cases. The choice of the bath is difficult and 
I am inclined to believe that the temperature of the waters and 
the mode of administering these baths are more important than 
the chemical ingredients the waters may contain; it is in most 
cases of small importance whether the water contains salt or 
carbonic acid or sulphids, or whether a mud or a fango bath 
is given. At home warm bathing should also be encouraged and 
the patient should, at least two or three times a week, take a 
hot bath, a few degrees above the body temperature, preferably 
lying still in the tub for ten minutes at a time. After the bath 
a vigorous rub with a rough towel, followed by a general mas- 
sage with cocoa butter or olive oil, is often of great value. Hot 
bathing of this kind, however, is distinctly contra-indicated 
in cases suffering from cardio-vascular or nephritic manifesta- 
tions of the uric acid diathesis, and immeasurable harm is un- 
doubtedly done in many of these cases by a routine treatment 
which ignores these elements. All hydro-therapeutic proced- 
ures, Turkish or Roman baths are, as a rule, too severe for these 
patients, particularly in view of the neurotic complications and 
also the changes about the heart and arteries that are present 
in the great majority of them. 

The medicinal treatment of the uric acid diathesis will be 
discussed in full in the Section on Nephrolithiasis Urica (see page 
230), and I refer to those paragraphs for the use and abuse, the 
fallacies and inconsistencies of most so-called uric acid remedies, 
particularly the uric acid "solvents." 

Certain complications and sequelae of the uric acid diathesis 
require special treatment. Many of these signs disappear 
promptly upon the onset of a regular gouty attack and most 
of them are best treated, like the complications of diabetes and 
obesity, by correcting the underlying metabolic perversion. In 
view of the important part that the state of the digestive appa- 
ratus plays in the production of lithemic manifestations, par- 
ticular attention should be bestowed upon the gastro-intestinal 
tract and the liver. Here the syndrome of functional hepatic 
insufficiency must always be considered and treated, as de- 
scribed in the Chapter on Diseases of the Liver (see page 488). 
If the diet is arranged as outlined above gastro-enteric symp- 
toms are not very liable to supervene; if they should appear, 



RETROCEDENT GOUT 185 

their symptomatic treatment differs in no way from that of 
other forms of gastric or intestinal dyspepsia, as elsewhere de- 
scribed. Constipation is very common and should be energet- Constipation 
ically combated. Intestinal putrefaction should never be per- 
mitted to go on unchecked. For this reason free evacuation of the 
bowel contents, either by the use of vegetable cathartics or 
preferably of salines, should be promoted, and, in addition, 
such remedies administered that we know can hold intestinal 
putrefaction in check. The latter have been discussed in full Catarrhal con- 
under the heading of Intestinal Antisepsis (see index). The dl tions 
chronic catarrhal conditions about the throat and respifatory 
apparatus; the skin affections; the "rheumatic" pains in the Anemia 
muscles; the anemia and cachexia; the nephritic manifesta- Diabetes 
tions; complicating diabetes and obesity, should all be attacked Q-beslt y 
by trying to correct the perversion of the patient's metabolism 
chiefly by diet, exercise and hydrotherapy, and, in addition, 
symptomatically as described under these different diseases. 

The tophi rarely call for special treatment. Particular care Tophi 
should be taken not to remove them surgically nor to allow pa- 
tients to try to squeeze or scratch the concretions out; for in 
the uric acid diathesis there is an increased vulnerability of 
the skin and subcutaneous tissues, so that even mild surgical 
procedures or surface injuries frequently induce erysipelas, 
cellulitis with ulcers and obstinate fistulas or even gangrene of skin lesions 
the parts. 

Before discussing the treatment of the acute attack of gout, Retrocedent 
the general principles that should govern the treatment of so- £ out 
called retrocedent or metastatic gout may ba briefly considered. 



RETROCEDENT GOUT. 

It is well known that occasionally the joint manifestations of Retrocedent 
gout will rapidly disappear and in their place a variety of dis- sont 
tressing and dangerous cerebral symptoms develop. The latter 
manifest themselves as cerebral gout by headache, vertigo and 
even apoplectic seizures (gouty encephalopathy) ; as cardiac 
gout by severe cardiac pain, syncope or collapse; as gastro- 
intestinal, vesical or cutaneous gout with corresponding mani- 
festations. 

The sovereign therapeutic indication in all of these cases is induction of 
to reinduce a regular articular paroxysm. This can best be done regular arti- 
either by placing the feet into hot mustard water or by rub- a parox y sm 
bing the dorsum of the foot, and particularly the large toe, 
with an alcoholic solution of turpentine f crowed by the appli- 



186 



THE ACUTE ATTACK OF GOUT 



cation of heat, and wrapping the parts in cotton. The cerebral 
symptoms, provided they do not promptly disappear when the 
articular paroxysm is produced, should be treated by the appli- 
cation of cold to the head and by venesection. If the stomach 
symptoms predominate, then vomiting should be produced by 
the use of emetics and counter-irritation over the epigastrium, 
preferably cold. The heart collapse calls for the use of analep- 
tics, scil. camphor, ether and the application of cold over the 
precordial region. 



Danger of 
aborting- acute 
paroxysms 

Local treat- 
ment 

Immobilization 



Lotions 



Anodyne ap- 
plications 



THE ACUTE ATTACK OP GOUT.* 

Any attempt to abort the acute paroxysm of gout is to be 
condemned ; for by suppressing local symptoms much danger can 
arise to the organism at large. The local treatment consists in 
the immobilization of the affected joint, the patient remaining 
in a recumbent position, at least in the beginning, with the 
diseased limb elevated and covered with cotton or flannel. No 
pressure should be exercised upon the affected joint. Cold 
should never be applied, because it retards the circulation and 
aggravates the local condition, and may even lead to the devel- 
opment of necrosis and to the permanent deposit of urates. 

A variety of lotions have been recommended for local use. 
Whisky and water applied on lint is very grateful, or a drachm 
of sulphuric ether in six ounces of water may be used. Lauda- 
num and water and belladonna liniment with morphia are rec- 
ommended by Garrod. 

The following liniment is advised by Duckworth: 

Atropin, 3 grains. 

Morphine hydrochlorate, 15 grains. 

Oleic acid, 1 ounce. 

M. 

S. To be painted over the painful joint with 

a large camel 's hair brush and carded cot- 
ton to be superimposed. 

Camphor-menthol, made by rubbing up together three parts 
of menthol with two of camphor, forms a useful anodyne applica- 
tion; or half an ounce of menthol may be dissolved in six 



♦Acute paroxysms of gout are rarely seen in this country. Inas- 
much, therefore, as my personal experience with this manifestation of 
the uric acid diathesis is relatively limited, I submit in broad outline 
the combined authoritative statements of Duckworth, Gorrod, Roberts 
and Latham on the treatment of this disease. 



THE ACUTE ATTACK OF GOUT 187 

ounces of spirits of camphor for a lotion. Any application that 
occludes the sweat ducts, like collodion or medicated powders, 

should be eschewed. Blisters and leeches should never be ap- Blist ers and 

leech.es 
plied, as the skin over the affected joints is usually very vul- 
nerable and there is always danger of producing obstinate ec- 
zema, furunculosis or even gangrene. Heat is always grateful, Heat 
preferably applied in the form of hot fomentations or poul- 
tices. Massage of the affected joint should be reserved until Massage 
the third or fourth day of the paroxysm, but had better not be 
administered in the beginning of the attack. Usually the pain 
produced by the massage, or by any movement of the joint, of 
itself forbids this measure. 

The internal treatment of the acute gouty attack consists Internal treat- 
in the administration at once of a purge. One or two grains of men 
calomel with two to six grains of the compound pill of colocynth 
and extract of hyoscj^amus (Pil. colocynth et hyoscj^ami, B. P.) 
should be given at night, followed in the morning by a Seidlitz Purging 
powder or some other saline aperient. 

As soon as the attack is fully developed colchicum becomes 
the sovereign remedy. This drug may be considered almost Colchicum 
a specific, at least for relieving the pain in a gouty paroxysm. 
In order to continue the laxative effect inaugurated by the cal- 
omel, colocynth and hyoscine, twenty grains of carbonate of 
magnesium may be added to each dose of colchicum. The fav- 
orite prescription employed in St. Batholomew's hospital is the 
so-called Haastus Colchici, containing: 

Magnesium carbonate, 10 grains. 

Tincture of colchicum seed, 20 minims. 

Peppermint water, • 1 ounce. 

This dose to be given every night; half the dose in the morn- 
ing. 

The treatment is continued for three or four days and then 
two or three grains each of the extract of colchicum, combined 
with a compound colocynth pill (see above), are given every 
night. 

The most satisfactory preparation of colchicum is the wine: 
for it does not possess such violent purgative properties as the Preparations 
preparations of the seed. The use of colchicine either by 
mouth or hypodermically is condemned as useless and not with- 
out danger by leading authorities. The symptoms of colchicine 
intoxication consist in depression, nausea and purging, and 
sweating, the stools assuming a characteristic green color. It 
is rarely necessary to give the drug in such large doses that 



188 



RACHITIS 



Sodium sali- 
cylate 



Anti-neuralgics 
Quinic acid 



Alkalies 



Diet 



Water 
Alcohol 



To prevent re- 
currences 



Iodides 



purging is produced. The appearance of severe depression and 
violent purging, and a great fall in the arterial pressure with 
profuse sweating, call for a reduction of the dose or temporary 
discontinuation of the remedy. 

Sodium salicylate also enjoys great popularity. In order 
to do any good it should be given in large quantities of from one 
to two drachms (4 to 8 gm.) a day, in doses of fifteen grains 
(1 gm.), repeated four or eight times during the twenty- four 
hours. Very frequently the good effects of salicylates persist 
only for two or three days, then the common anti-neuralgics, 
phenacetin, antipyrin, aspirin, etc. (see index), may be given. 
Urocine and sidonal, the former the lithium salt, the latter 
the piperazin salt of quinic acid, are also recommended, but 
they are by no means so effective nor so reliable as colchicum 
or the salicylates. Most clinicians speak very highly of the 
use of the alkalies, viz., sodium, potassium and lithium carbonate 
or citrate, in acute gout. 

The diet during the acute paroxysm should consist largely 
of milk, bread, toast, crackers and cereals, and broths. Fresh 
fruits and vegetable acid foods should be omitted from the 
dietary. The patient should drink large quantities of water, 
preferably some alkaline mineral water. Alcohol should be 
absolutely forbidden. 

In order to prevent the recurrence of acute attacks of gout 
during the stage of convalescence, the wine of colchicum, given 
in small doses, is the best remedy. Duckworth recommends five 
or six drops of the wine or tincture twice a day, or a grain of 
the extract in pill at night, to be continued for a long time after 
the subsidence of the acute attack. 

Occasionally the pain in the joint persists for a long time 
after the acute paroxysm is over ; here the iodide of potassium or 
of ammonium, in doses of five grains (0.3 gm.) three times a day, 
preferably combined with five to ten drops of the wine of col- 
chicum, is the best remedy. 



V. RACHITIS. 
Definition This disease, as the names rachitis and rickets indicate, is 

commonly interpreted to be a disease of the bony structures of 
the body. While the bony deformities are a prominent symp- 
tom they are by no means the determining manifestation of the 
disease. Rachitis must be regarded as a general nutritional, i. e., 
a metabolic, disorder. The diagnosis, it is true, is, as a rule, 
made from the bony changes, namely, the square head, the 



RACHITIS 189 

open fontanelles, the beaded ribs, the enlarged bone ends, the 
curved arms and legs, the pigeon breast, the contracted pelvis, 
the deformed spine, and backwardness in teething. As import- 
ant as the osseous deformities, however, are the involvement of 
the lymph glands and the enlargement of the liver and spleen, 
the general muscular flabbiness, the anemia, the catarrhal con- 
dition of all the mucous membranes and the instability of the 
motor system with the well-known tendency to convulsions, 
tetany, laryngismus stridulus, glottis spasm, and tonic contrac- 
tions about the hands and feet. 

Intelligent prophylaxis can often prevent the onset of the prophylaxis 
disorder. That we may institute the necessary preventative 
measures and properly treat the disease after it is fully devel- 
oped, it is necessary to analyze the underlying etiological ele- 
ments that produce rachitis. A great number of factors have 
been accused of causing rickets. An inherited tendency has been 
incriminated, as well as congenital syphilis, poor general 
hygiene, lack of light and air, and, above all, a variety of food 
factors. A careful analysis of all these causes shows that the 
most important element of all is the food factor. 

As far as the hereditary element is concerned there is no Hereditary 
definite evidence to show that rachitic parents are more apt element 
to have rickety children than healthy parents. This is readily 
understood when one considers that rickets is a disease of child- 
hood and never persists into adult age so that the existence of 
rickets in the parent at one time may not be easy to determine. 
As a matter of fact, rickety children, as a rule, are the off- 
spring of healthy parents who never showed rickety tenden- 
cies during their childhood. Fetal rickets, so-called, is prob- 
ably not rickets at all, but a form of cretinism. Congenital rick- 
ets undoubtedly occurs, but only if the health of the mother is 
poor; here a nutritional and not an hereditary element is a1 
play. 

Congenital syphilis, according to the best authorities, does syphilis and 
not produce rickets. In most cases of rickets the typical syph- rickets 
ilitic phenomena are absent and, on the other hand, most cases 
of congenital syphilis do not show rickety signs. The com- 
bination of the two undoubtedly can, and frequently does, occur, 
and in this way a peculiar disease picture is created in which 
it is often difficult to distinguish the syphilitic from the rachitic 
elements. 

That lack of light and air, and life in damp, dark dwellings General 
alone cannot produce rickets is made manifest by the frequent hy £ iene 
appearance of rickets in children of the well-to-do classes who 
live under ideal hygienic conditions. That malhygiene by fav- 



190 



RACHITIS 



Quantity of 
the food 



What elements 
are deficient? 



Lime salts 



Lactic acid 



Three elements 
lacking, viz., 
fat, proteid, 
and earthy . 
phosphates 



oring malnutrition and lowering the tone of the infantile or- 
ganism can favor the development of rickets, provided food 
errors are at the same time committed is, of course, self-evident. 
A child, however, may live in the most unhealthy surround- 
ings without developing rickets, provided it is fed according to 
correct principles. 

That the quantity of food, finally, does not produce rickets 
is made clear by the appearance of the disease in fat children, 
while, on the contrary, children in advanced stages of atrophy 
may not develop, in fact, rarely do develop, rickets. Broadly 
speaking the statement can be made that qualitative, and not 
quantitative, errors of feeding produce most cases of rickets. 
It is also important to note in passing that breast-fed children, 
provided the mother is healthy, hardly ever develop rickets, 
whereas, children who are fed on artificial foods, particularly of 
the farinaceous variety, are very apt to develop the disease, un- 
less a sufficient quantity of animal albumen and fat, as will be 
presently shown, is added to the diet. 

The question arises what elements are deficient in the food 
of children who develop rickets; and what elements must 
therefore be supplied in order to prevent the development of 
the disease? 

As the percentage of lime salts in rachitic bones is below 
normal, the theory has been advanced that the disease is due 
to deficient mineral matter, especially lime salts, in the food. 
This postulate is refuted by the observation that children living 
on farinaceous foods which contain an abundance of lime salts 
are particularly liable to develop the disease, and by the further 
observation that the addition of lime water to artificial foods is 
in no way capable of preventing rickets. 

Some clinicians believe that the lactic acid produced by the 
fermentation of imperfectly digested starchy foods in the 
stomach, can be made responsible for the development of rickets; 
they assume that lactic acid entering the circulation dissolves 
the lime out of the bones. This theory is opposed by the ob- 
servations that rickets develops in individuals who are not suf- 
fering from fermentative dyspepsia and who readily assimilate 
all the starchy food that is given them; besides, rickety chil- 
dren improve rapidly if the farinaceous diet is continued and 
if only sufficient proteid and fat is added to the diet. Finally, 
free lactic acid could never circulate in the blood, for it would 
at once combine with alkalies and circulate as lactate, that is, 
in a form that could not dissolve the lime salts of bones. 

The preponderance of all positive evidence submitted in- 
dicates clearly that in all cases of rickets three elemeots chiefly 



RACHITIS 191 

are lacking from the food; namely, a sufficient quantity of ani- 
mal fat, of animal proteid and of earthy phosphates. 

Cheadle expresses himself as follows in regard to the deficit 
of fat, proteid and lime phosphate in rickets: "The depend- 
ence of rickets on the deficiency of these three elements of food 
would explain something more than the mere bone changes; it 
would clearly explain the imperfect nutrition of brain, muscle 
and nerve structure, which mere excess of lactic acid or absence 
of lime salts would not account for. It explains, moreover, why 
rickets is so prevalent in large towns and dense populations, 
where milk is so scarce and dear, deprived of cream and water- 
ed, and the poor driven to feeding their children on the cheaper 
farinaceous foods." 

One other etiologic factor must be mentioned, viz., chronic Gastro-intes- 
gastro-intestinal disorders, especially if they produce vomiting tinal disorders 
and diarrhea. Whenever such disorders are present the child 
practically becomes starved despite the administration of plenty 
of food; the proteids and fats chiefly are wasted under these 
circumstances because they must undergo certain preliminary 
changes, which require time, before they can be assimilated, 
whereas, the carbohydrates, being ingested largely in the form 
of sugar of milk, are promptly absorbed. This explains why 
cases of rickets occasionally develop in dyspeptic children who 
are fed on good cows' milk diluted in the proper proportion and 
containing all the elements that make up the correct diet for 
the child. 

From all that has been said the prevention and cure of rick- Prophylaxis 
ets is a comparatively simple problem, and in few diseases are 
so gratifying results obtained from proper feeding. In rickets, 
above all things, the gastro-intestinal tract, for reasons mention- 
ed in the preceding paragraph, should be treated in such a way 
that catarrhal conditions are corrected. The food, moreover, 
should contain an abundance of animal proteid, of animal fat 
and of phosphate of lime. 

In view of the fact that many children cannot digest large j law mea t 
quantities of milk casein, which would be the ideal proteid, the juice 
deficiency of animal albumen must often be supplied by raw meat 
juice. This is prepared as follows : Steak is finely chopped up 
and stirred with cold water in the proportion of one part of 
water to four parts of meat ; this mixture is allowed to stand for 
half an hour in the cold and the juice is then expressed through 
a cloth or through a meat press. The meat juice obtained in 
this way is very rich in albumen and extractives and consti- 
tutes an ideal means of supplying nitrogen. The meat juice 



192 



Cream and cod 
liver oil 



Lime 



Lacto-phos- 
phates 



can be mixed with milk without coagulating it and without per- 
ceptibly flavoring it. It also renders the milk coagulates fine 
and flocculent. The quantity of this raw meat juice that may 
be given in the place of casein is from one and one-half to three 
ounces in the twenty-four hours. In preparing an artificial mix- 
ture with meat juice the amount of casein, therefore, that is 
withheld should be calculated and an equivalent amount of meat 
juice added* 

That the meat juice should be prepared fresh every day and 
kept in a cool place need hardly be emphasized, for, otherwise, 
decomposition, with the formation of highly irritating poison- 
ous products, may occur. The deficit of fat should be made up 
by the addition of a sufficient quantity of cream. Cream is the 
best source of fat for the infant and is to be preferred to cod- 
liver oil. If cream cannot be borne codliver oil may, however, 
be found very useful; dose, a teaspoonful two or three times a 
day. Lime should not be supplied as lime water, for the lat- 
ter, as stated above, does not seem to fulfill the desired purpose. 
As a rule, if raw meat juice is given, or if plenty of good milk 
is used in the preparation of the artificial food, the addition 
of lime phosphates is rarely necessary. If lime salts, however, 
must be supplied artificially, then they can very advantageously 
be given in the form of the lacto-phosphate prepared as follows: 

Calcium phosphate, 12.5 

Lactic acid, 15.0 

Distilled water, 330.0 

Sugar of milk, 630.0 

Tincture aurant q. s., ad., 1000.0 
M. 

Dose, two to four dessertspoonfuls a day. 

( Ortner. ) 

Or the calcium lacto-phosphate may be given in water as 
follows: 



I* 



Calcium lacto-phosphate, 

Water, 

M. 

A dessertspoonful three times a day. 



15.0 

200.0 



*The rules governiug the exact proportions of protcids, fats, carbo- 
hydrates and mineral salts that shoufd be contained in the different 
artificially prepared infant foods for different ages cannot be discussed 
within the narrow frame of this book. I must refer for information on 
this subject to text-books on Pediatrics. 



OSTEOMALACIA 193 

Some very capable clinicians recommend the administration phosphorus 
of phosphorus in this disease; others, again, claim that its ad- 
ministration is unnecessary, provided the above dietetic rules 
are carefully carried out. Nevertheless, good results occasionally 
accrue from phosphorus treatment. The remedy is best given 
in combination with codliver oil, according to the following 
formula : 

Phosphorus, 0.01 

Codliver oil, 100.00 

M. 

This mixture contains about y 2 mg. phosphorus to the tea- 
spoonful ; one or two teaspoonf uls a day should be given. Hydrotherapy- 

Hydro-therapy, too, has a place in the treatment of rickets. 
Cold applications are dangerous in the fully developed stages 
of the disease. As a prophylactic measure, however, bathing 
the infant daily with warm water that is gradually cooled down 
to 20° C. is exceedingly useful. 

The extremities and the spinal column of the child should Orthopedics 
be protected against the development of deformities by forbid- 
ding standing and by carrying the child in such a way that no 
curvature of the spine or extremities can develop. The tech- 
nique of these self-evident precautionary measures, as well as 
the correction of the fully developed deformities, belong to the 
field of Orthopedics and Surgery and need not be elaborated 
upon in this volume. 



VI. OSTEOMALACIA. 
~ i • • i i ! t . t -.i -,. Phosphorus 

Osteomalacia is closely related to rickets, and the medica- and codliver 

mentous treatment of the two diseases is practically the same. 0l1 

Here the combination of phosphorus and codliver oil that has 

been mentioned above is particularly useful. Inasmuch as this 

disease usually develops in adult life, the dose of phosphorus 

may be larger than in an infant, as much as 4 to 6 mg. of 

phosphorus being administered during the day and continued 

for months. Sometimes codliver oil is not well tolerated and 

then phosphorus in the dose of 0.01 gm. may be given in the 

form of pills or in chocolate-coated tablets. Calcium has been „ , . 
_ Calcium 

frequently recommended in the treatment of osteomalacia, and 

it can do no harm to give these patients ten to fifteen grains 

of a mixture of calcium carbonate and calcium phosphate in 



194 



DIABETES INSIPIDUS 



Anemic medi- 
cation 



Atropine 



Diet and 
liygiene 



capsule several times a day. Inasmuch as many of these patients 
are anemic, the following capsule is useful : 



5 



1-100 gr. (1 mg.) 

2 grs. (0.1 gm.) 

5 grs. (0.3 gm.) 

10 grs. (0.6 gm.) 



Arsenious acid, 

Reduced iron, 

Calcium phosphate, 

Calcium carbonate, 

M. 

One such capsule three times a day. 

A form of treatment that has been warmly recommended 
recently is the use of atropine. Its action in osteomalacia is 
altogether obscure. The dose should be regulated according to 
the appearance of symptoms of atropine poisoning. It is always 
well to begin with small doses of about one-two-hundredth grain 
three times a day, and gradually to increase the dose until 
atropine symptoms appear, as manifested by dryness of the 
mouth, dilatation of the pupils, etc. 

The diet in osteomalacia should be arranged according to 
similar principles as the diet in rachitis, i. e., there should be 
an abundance of albuminous and fat food. The state of the 
digestive apparatus should be carefully regulated, and ideal 
conditions as regards light and air and dwelling should be cre- 
ated. Here, too, during the florid stage of the disease the pre- 
vention of deformities and contractures must be considered. The 
orthopedic and surgical measures employed are the same as 
those in rachitis and cannot be entered into here. 



Definition 



Symptomatic 
polyurias 



VII. DIABETES INSIPIDUS. 

Diabetes insipidus is a name employed loosely to designate 
a variety of symptomatic polyurias that may be due to different 
causes. Provided one is dealing with a simple polyuria not due 
to cardio-vascular or renal disease, then the possibility of a 
cerebral or spinal origin, or of hysteria, must be seriously taken 
into consideration in every case and treatment instituted ac- 
cordingly. In view of the fact that a number of syphilitic le- 
sions of the cerebro-spinal axis are capable of producing symp- 
tomatic polyuria, every case of diabetes insipidus that does not 
yield to the measures to be presently described, should be given 
the benefit of an energetic antiluetic treatment. In such cases 
very large doses of iodide of potash, i. e., as much as two hun- 
dred or three hundred grains a day, preferably combined with 
mercury inunctions or Irypodermic injections of mercury salts, 
should be given (see Syphilis). 



DIABETES INSIPIDUS 195 

The treatment of hysterical polyuria, which is often called Hysterical 
diabetes insipidus, is synonymous with the treatment of hys- po y^ 19 - 5 
teria. Quite a few cases of so-called diabetes insipidus are on 
record for instance that were cured by hypnotism, others again 
by carefully carried out rest treatment or hydro-therapeutic 
measures directed against the underlying hysterical perversion. 

In view of the fact that most sufferers from diabetes in- Valerian 
sipidus are nervous people, valerian, bromide of potash, cam- Bromides 
phor, asafetida and antipyrin all have a distinct field of use- . S ^. e * . a 
fulness in this disease. I have never seen any good results 
follow the use of atropine or of other preparations of bella- 
donna that have been recommended for the purpose of "check- 
ing the secretion of the kidneys;" the dryness of the mouth, in 
fact, which atropine produces usually increases the thirst and 
hence favors rather than checks the polyuria. 

Ergot may be used and not infrequently produces good re- Ergot 
suits. Its exact mode of action is not understood, but it pre- 
sumably exercises its effect upon the blood vessels of the kid- 
ney. Its action can best be explained as follows: The amount 
of urine excreted depends upon the blood pressure in the 
glomerules and the more the renal arteries become contracted 
under the influence of ergot the smaller the amount of blood 
that enters the glomerules and the smaller consequently the flow 
of urine. 

A measure that is often useful is galvanization of the Galvanization 
sympathetic in the neck, as described under Exophthalmic of tne cervical 

S"VHlT)£L'fcllG'fcic 

Goitre (see page 106). It is not impossible that the galvanic cur- 
rent directed from the angle of the jaw to the back of the neck 
into the region of the lower cervical vertebra? actually exercises 
an effect upon the medulla itself which may reduce the polyuria. 
This assumption, however, is difficult to prove and the element 
of suggestion from the electrical treatment can never be ex- 
cluded, especially in a disease which is so so commonly combined 
with hysteria. Electricity, however, should be given a fair 
trial. 

The most rational procedure of all is to reduce the liquid „ , 

. . Reduction of 

intake, and at the same time to promote the elimination of water the liquid 

through other emunctories of the body than the kidney. Drink intake 
restriction, as a rule, exercises a pronounced effect upon 
the amount of excreted urine, in fact, some cures have been re- 
ported from complete withdrawal of liquids for a period of 
twenty-four or forty-eight hours. This procedure is exceedingly 
irksome to the patients and requires the exercise of much will 
power. The distressing thirst can be counteracted in a measure 
by smoking, chewing gum or swallowing small ice pills. In 



196 DIABETES INSIPIDUS 

order to carry out the thirst treatment properly it is usually 
Sweating necessary to put the patients to bed and to treat them as one 

would an hysteric under restraint. If it is desired to sweat the 
patients, pilocarpine may be given to advantage, preferably 
hypodermically in the dose of 0.01 to 0.015, twice daily; or the 
hydro-therapeutic measures for promoting diaphoresis that have 
been fully described on pages 42, 43 may be utilized. 



CHAPTER V. 



DISEASES OF THE URINARY APPARATUS. 

I. NEPHRITIS. 

The classification of nephritis, if we are to follow orthodox Classification 
standards, is highly confusing. From the anatomic, i. e., de- 
scriptive pathologic standpoint, the matter is simple enough; 
from the clinical, i. e., the diagnostic and therapeutic stand- 
point, the anatomic classification is in a large measure useless. 
Clinically, we should distinguish (1), an acute nephritis; (2), 
a chronic parenchymatous or interstitial nephritis developing 
either consecutively to an acute nephritis or slowly and insid- 
iously from the beginning; (3), different types of "vascular" 
nephritis (cardio-renal disease), i. e., of nephritis due to im- 
paired circulation in the kidneys with resulting degenerative 
changes in the organ; to the latter category belong, e. g., the 
nephritis of Bright 's disease, in the modern sense, and the ne- 
phritis of arterio-sclerosis. 

The matter is further complicated by the fact that in all 
forms of chronic nephritis cardio-vascular signs develop sooner 
or later; so that it is often a difficult matter to determine 
whether the changes about the heart and arteries are the pri- 
mary event that produces the nephritis, or whether the nephritis 
causes retention of excrementitious bodies that poison the heart 
and arteries, or, finally, whether the same primary cause simul- 
taneously affects both the cardio-vascular apparatus and the 
kidneys. From a therapeutic point of view it is very import- 
ant to decide this matter, and I intend in the following dis- 
cussion of chronic nephritis to consider as belonging to the sec- 
ond category those forms in which the cardio-vascular signs 
appear after the nephritis, and to the third category ("vascular 
nephritis") those forms that are either directly preceded by, 
and traceable to, cardio-vascular disease or that develop simul- 
taneously with cardiac and arterial disturbances. 

As far as the further differentiation of nephritis into the 
parenchymatous and the interstitial forms is concerned, I con- 
sider that unimportant in the therapeutic sense, for there is 
never a parenchymatous inflammation without some interstitial 
changes, nor vice versa. The involvement of the renal paren- 
chyma or of the interstitial tissues of the kidney will depend 
altogether upon the kind, the virulence, the selective affinities 
of the various toxic and infectious agents that produce the 



198 



ACUTE NEPHRITIS 



nephritis, upon the length of time during which they irritate the 
kidneys and upon the path by which they reach them. Gener- 
ally speaking the more chronic the nephritis the more marked 
the interstitial changes. In the vascular type, too, interstitial 
changes usually predominate. 



Prophylaxis 



Abundant wa- 
ter drinking- 



Restriction of 
liquids 



Diet 



ACUTE NEPHRITIS. 

To the kidneys is relegated the chief disintoxicating func- 
tion of the organism, hence they are particularly susceptible to 
injury by any toxic or infectious material that may gain en- 
trance to the circulation. Recognizing this fact it is occasionally 
possible, in certain infectious diseases, to prevent the develop- 
ment of nephritis as a complication, first, by giving such abund- 
ant quantities of fluid early in the disease that whatever toxins 
are carried through the renal filter are thoroughly diluted and 
hence not so apt to irritate and inflame the renal epithelia in 
transit; second, by avoiding the administration of remedies that 
can irritate the kidneys.* In some diseases, moreover, energetic 
causal treatment instituted early may save the kidneys; thus in 
malaria an active quinine treatment may often prevent the de- 
velopment of nephritis, and in syphilis, paradoxical as it may 
sound, an energetic mercury treatment may also prevent renal 
complications, notwithstanding the fact that mercury in itself 
is capable of irritating the kidneys. 

The administration of abundant quantities of water in acute 
infectious diseases is a useful procedure, only, however, while 
the renal filter is still permeable for water and before pro- 
nounced nephritic changes have appeared. When nephritis has 
once set in the administration of water should be reduced con- 
siderably, at least during the period of acute inflammation, and 
the administration of large quantities of water should not be 
resumed until the nephritic process is in course of healing. One 
should be guided, in this matter, largely by the function of the 
kidneys ; when they stop excreting abundantly it is bad practice 
to try to force them to eliminate water, and one should wait 
with abundant water-drinking until the kidneys indicate by in- 
creased diuresis that they are again capable of excreting water. 
Of this more below when discussing the diet in acute nephritis. 

The diet, in acute nephritis, should, during the stage of in- 
flammation, be scanty and bland. The principle of sparing the 
kidneys by relieving them of the task of excreting much solid 



♦Salicylic acid preparations, chlorate of potash, most of the bal- 
sams, tar, turpentine, cantbarides, etc. 



ACUTE NEPHRITIS 199 

excrement is the prime indication and should be carefully ob- 
served. In certain infectious diseases of short duration it is not 
a bad plan to withhold food altogether for a period of two or 
three days, allowing the patient only enough water to allay the 
thirst and to compensate for the loss of water through the 
breath and the sweat glands. This treatment is heroic, but, starvation, 
especially in children, the results are so gratifying as to warrant 
its employment. The fact that the patients are forced to con- 
sume their own tissues and are inadequately nourished by this 
procedure need not militate against the starvation treatment, 
inasmuch as under-nutrition, lasting for two or three days 
only, can do no harm. In chronic forms of nephritis the starva- 
tion plan, or even continuous under-feeding, with the object of 
sparing the kidneys, is, of course, never permissible, as will be 
shown at length hater on. 

If one is justified in assuming that the acute nephritic in- 
flammation will last longer than two or three days, or if the 
renal complication does not rapidly yield to complete with- Milk 
drawal of food, then milk is the best nutrient. It should con- 
stitute, in acute nephritis, the only food until the nephritic pro- 
cess has entered into the sub-acute stage. Occasionally a patient 
cannot bear milk, either on account of an aversion to it, or on 
account of inability to digest it; in such cases the administra- 
tion of small quantities of milk, in tablespoonful doses, given 
ice cold and possibly with the addition of a little lime water or 
some flavoring extract, will often render its administration pos- 
sible. If there is complete intolerance or aversion to milk, then Buttermilk 
buttermilk or kefir or kumyss can frequently be borne, and Kumyss 
while these beverages do not possess the nutritive value of an 
equivalent of milk, still they serve a very useful purpose. The 
quantity of milk must vary according to the individual case, 
but more than one litre should rarely be given during the 
twenty-four hours. In order to increase the nutritive value of 
the milk cream may be added ; a tumbler full of milk-cream mix- 
ture, containing four parts of milk and one part of cream, 
with one tablespoonful of lime water, administered every two 
or three hours, suffices to adequately nourish the patient, and 
at the same time to spare the kidneys during the acute and sub- 
acute stages of the nephritis. 

During the stage of healing it becomes necessary to nour- Diet during 
ish the patient more generously. This can be done with safety the stage of 
by allowing soups made of oatmeal, rice and barley, a little bread 
or zwieback, some fresh fruit and boiled vegetables. Meat ex- 
tracts or bouillons exercise a beneficial and stimulating effect 
upon the appetite and the gastric digestion without, at the same 



200 



ACUTE NEPHRITIS 



Meat 



Hest 



Position in bed 



Catching cold 



Clothing dur- 
ing conva- 
lescence 



'Symptomatic 
treatment 



Counter-irri- 
tants to renal 
region 



time, containing elements that markedly irritate the kidneys; 
nor do they, it is true, contain any elements that are particularly 
nourishing, hence they can hardly be considered a food, as their 
caloric value (see page 157) is very small. Later the ordinary 
mixed diet should be resumed, always under careful supervis- 
ion of the urine, in order to control the effect of a liberal diet 
upon the healing of the nephritic process. 

Meat should preferably be withheld until the healing is well 
advanced. I do not think that the kind of meat makes much 
difference, although possibly, in honor of an old fashioned prej- 
udice, light meats may be given the preference over dark meats. 

As soon as symptoms of acute nephritis make their appear- 
ance the patient should be put to bed and kept absolutely quiet 
until the inflammation of the kidneys subsides. As a rule 
nephritic cases lie on their back, but it is a very good plan, if 
they can comfortably do so, to have them lie on the abdomen, 
at least during part of the day. They should at all events fre- 
quently change their position in bed, for in this way, hypostatic 
congestion of the kidneys is prevented, and, in many cases, 
the pain in the lumbar region is markedly reduced. The pa- 
tient should remain in bed until the albumin has disappeared 
from the urine. Even after this stage has been reached, the 
patient should at first arise for a short time only each day, and 
never within an hour or two after a meal. The urine should 
be carefully controlled daily and the patient ordered back to 
bed as soon as albumin reappears upon exertion. Unless this 
precaution is taken chronic nephritis is very apt to develop. 

Nephritics or individuals who have just recovered from 
acute nephritis are very liable to catch cold. Possibly there is 
in such cases a lowering of the tone of the vaso-motor centres 
as a result of the renal intoxication. Particular precautions 
should be therefore taken to prevent taking cold, according to 
the principles discussed on page 266. Convalescents from acute 
nephritis should at all events always wear a flannel binder cov- 
ering the kidney region for many months after recovery, and 
should be warned particularly against exposing themselves to 
wet or cold. 

The symptomatic treatment of acute nephritis includes 
among other things the relief of the pain in the kidney region 
that is often quite distressing. Remembering always that no 
drug should be given in nephritis that can irritate the kidneys, 
care should be taken in selecting proper counter-irritants to be 
applied to the lumbar region. Thus cantharidal ointments or . 
plasters, or mustard poultices and plasters, that are very use- 
ful as revulsives, should never be used in acute nephritis. Cup- 



ACUTE NEPHRITIS 201 

ping or the application of leeches is, however, a very useful 
treatment for the relief of renal pain. The galvano-cautery may 
be employed to advantage, especially when applied over Petit 's 
triangle,* for the veins in this area anastomose with the veins 
of the renal capsule so that congestion within and around the 
kidneys can be effectively relieved by counter-irritation over 
this particular point. Cups, leeches or the cautery may be 
advantageously applied throughout the whole duration of the 
acute stage, for they can never do any harm and frequent]} 7 
seem to exercise a very beneficial effect, especially upon the 
pain and the reflex nervous symptoms of renal origin, viz., the 
headache, nervousness and vomiting. 

Different drugs have been recommended from time to time Drugs to re- 
for reducing the albuminuria. Aside from the fact that the ur [* a umm " 
excretion of albumin is a symptom of subordinate importance 
as far as any effect upon the nutrition of the patient is con- 
cerned, so that it hardly calls for special treatment, the various 
remedies used cannot be considered efficacious even to fulfill the 
purpose for which they are intended. They are mentioned 
merely on account of their historical interest. Thus tannin and 
tannalbin, methyl violet and methylene blue, strontium bromide 
and ichthyol and sodium benzoate, fuchsin and nitric acid all 
have their advocates, but none of them, in my experience, is 
of any benefit whatsoever in the treatment of acute nephritis. 

In case there is very much hematuria ergot may be given, Hematuria 
although the loss of blood is usually too insignificant to war- 
rant special consideration. Ergot should be given in the form 
of the fluid extract, 15 m. to 1 dr. (1.0 to 4.0) or the infusion 
1 to 2 oz. (16 to 32 cc). 

The suppression of urine occasionally calls for treatment Anuria 
although as a rule it is best to allow Nature to take its course 
and to wait a few days without active interference until the 
kidneys spontaneously resume their function (see also page 210). 
To force the kidneys to pass water always means to irritate 
them; there is, moreover, no tangible evidence to show that the 
promotion of diuresis by drugs really promotes the elimination 
at the same time of large quantities of urinary solids, so that 
the slight advantages accruing from forced diuresis are, as a 
rule, more than counter-balanced by the damage inflicted upon 
the kidneys by the diuretics employed. 

The elimination of retained urinary bodies should, therefore, Vicarious 
be promoted not by crowding them through the kidneys but eliminatlon 
by favoring their vicarious elimination through the bowel, and, 

♦Petit's triangle is the area bounded by the crest of the ilium below, 
the latissimus dorsi and the external abdominal oblique on each side. 



202 



ACUTE NEPHRITIS 



Milk as a 
diuretic 



Alkalies the 
only legitimate 
diuretic in 
acute nephritis 



Diuretics in 

dangerous 

edemas 



Heart tonics 

Digitalis and 
caffein 

Acetate of 
potash 

Calomel 
Diuretic teas 



so far as that is possible, through the sweat glands. It is more 
important, as shown above, to regulate the diet in such a way 
that only small amounts of excrementitious bodies have to clamor 
for elimination through the closed renal filter, than to feed in- 
judiciously and try to force urinary bodies through a barrier 
that Nature has closed for the time being. It is well to remem- 
ber that the chief task, in the treatment of nephritis, as of any 
other acute disorder, is to imitate Nature and to enforce her 
methods, viz., to spare the diseased organ and to keep it at rest, 
in order to enable it, as quickly as possible, to resume its normal 
function. 

Milk itself stimulates diuresis in a perfectly physiological 
manner, and if the patient with nephritis fails to pass a suffi- 
cient quantity of urine on an abundant milk diet, then this, in 
itself, is evidence that the kidneys cannot react to the stimulus 
even of mild diuretics. The reduction of the flow of urine, on 
a milk diet, is, therefore, prognostically, a bad sign and should 
induce us to be particularly careful not to irritate the in- 
flamed kidneys still further by the use of strong diuretics. 

The only legitimate diuretics, in the sub-acute stages of ne- 
phritis, are alkalies and alkaline mineral waters, preferably 
given in combination with milk. They act either by their effect 
upon the osmotic pressure of the blood in the kidneys and 
hence favor diuresis by their physical properties, or they pro- 
duce, as some authors claim, a reduction in the renal congestion, 
without in any way irritating the diseased renal cells. 

If the patient is suffering from severe edemas and an ac- 
cumulation of fluid in the serous cavities large enough to en- 
danger life mechanically by pressure, and if sweating and ac- 
tive catharsis do not relieve these dropsical swellings, then re- 
course must occasionally be had, as an emergency measure, to 
strong diuretics. As the heart in the great majority of these 
cases is affected (so-called nephritic edemas generally being 
cardiac edemas), heart tonics should always be administered 
in combination with a diuretic. 

No combination is more useful in such cases than the one 
described on page 43, in discussing cardiac dropsy, namely, digi- 
talis with caffein. The acetate of potash is commonly used; it 
acts as any other alkali for it reaches the kidneys in the form 
of potassium carbonate. Calomel, too, may be used for its 
diuretic properties in these extreme cases, and should be given 
as described under cardiac dropsies on page 43. Diuretic teas 
are very popular with the laity; it is doubtful whether the 
herbs that are used in their preparation possess very strong 
diuretic powers; the ingestion of large quantities of hot 



ACUTE NEPHRITIS 203 

water, however, without doubt stimulates the function of the 
sweat glands and possibly also of the kidneys, while the herb 
infusion can do no harm. One of the best of these teas is com- 
posed of equal parts of Fol. Uva Ursi and Herba Hernearia 
Glabra; a cup of tea made with half a teaspoonful of this mix- 
ture of the two dried herbs and sweetened with sugar should 
be given every two hours; especially in sub-acute nephritis a 
profuse diuresis can usually be stimulated by this mixture while 
the sweat glands also become very active. 

Most cases of acute nephritis are benefited by the use of Hydrotherapy 
lukewarm baths given for fifteen minutes at a time and accom- 
panied by friction of the surfaces of the body. Such a bath 
should be given once a day. The effect of this practice upon 
the blood pressure becomes manifest, as a rule, by increased 
diuresis and sweating. If it is desired to produce profuse 
sweating, then hot baths of 35° to 40° C., should be given and sweating- by 
the patient afterwards wrapped in warm blankets. If a pro- hot baths 
fuse sweat is produced in this way, the patient should, at the 
same time, be given abundant quantities of water to drink, as 
otherwise concentration of the body fluids may be brought about, 
hence their toxicity be increased and the danger of uremia en- 
hanced. 

One might ask what benefit could accrue from sweating on Sweating and 
the one hand and giving abundant water on the other, especially abundant wa- 
if, as claimed above, little poisonous material is eliminated by 
the sweat glands. The main effect produced is an active cir- 
culation of the lymph which acts beneficially by increasing met- 
abolism, by preventing stagnation and accumulation of toxic 
material in certain portions of the body, where they might 
do particular harm, especially in certain areas of the nervous 
system. 

One of the most convenient methods for producing diaphore- sweating bv 
sis is by means of the hot air bath, as described under cardiac hot air 
dropsy (see page 42) or by the use of large Priessnitz com- 
presses covering the whole body. In promoting sweating by the sweating- by 

Priessnitz method, a sheet is wrung out of hot water, wrapped not com- 

presses 
around the patient and covered with two or three woolen blank- 
ets. In order to forestall dyspnea and reactive cerebral hyper- 
emia, the patient should be placed in a semi-recumbent position 
and the head kept cool with cold cloths or an ice bag. As the 
patients usually soon complain of thirst they should be given 
plenty of cold water to drink during the sweating. 

Pilocarpine, bv subcutaneous injection, also produces a „ 
• „ Sweating by 

profuse sweat, but this drug should only be used if the heart pilocarpine 



204 



CHRONIC NEPHRITIS AND BRIGHT S DISEASE 



is altogether intact. I consider pilocarpine dangerous in heart 
disease and generally superfluous in nephritis. 

Catharsis Mild catharsis may to advantage be promoted. Great care 

should, however, be taken not to administer drugs that can irri- 
tate the bowel, for upon the bowel chiefly is thrown the task of 
vicariously ridding the system of excrementitious bodies that the 
kidneys are for the time being unable to excrete. Any derange- 
ment of the bowel function, therefore, should be most strenu- 
ously avoided; the same applies to the liver, for it, too, assumes 
a disintoxicating and a vicariously eliminating function in ne- 
phritis. For these reasons calomel and all drastic purges should 
be used only as an emergency measure in extreme cases. To 
evacuate the bowel castor oil or cascara, of the extract two to 
eight grains (0.12 to 0.5 gm.), of the fluid extract ten to fifteen 
minims (0.6 to 1 cc), may be safely given. Saline purgatives 
are to be avoided, for most salts either irritate the kidneys or 
are eliminated with difficulty by the kidneys when they are dis- 
eased. 

Heart tonics That it may occasionally become necessary to supply digi- 

talis as soon as the heart begins to flag in acute nephritis, is 
self-evident. It is not good practice, however, to give digitalis 
in the beginning for the sake of its diuretic effect, because, in 
acute nephritis, a great strain is always thrown upon the heart 
sooner or later and it is decidedly dangerous to stimulate it 
with heart tonics before there is an urgent call for their em- 
ployment. 



Cardio-renal 
disease 



The newer con- 
ception of 
Bright's dis- 
ease 



CHRONIC NEPHRITIS AND BRIGHT 'S DISEASE. 

In addition to those forms of chronic nephritis that develop 
consecutively to acute nephritis, we have a variety of forms in 
which the involvement of the kidneys is merely one symptom of a 
general toxemia, and in which the disorder about the heart and 
arteries dominates the picture. In some forms the disease seems 
to affect the kidneys first, and later the heart and arteries; in 
others the toxemia seems to involve simultaneously the heart and 
arteries. 

The latter variety, according to our newer idea, is true 
Bright 's disease. It is unfortunate that the name Bright 's 
disease is retained at all in our medical nomenclature, for what 
we understand by this term, and what Richard Bright origin- 
ally described, are two very different things. It is still more 
unfortunate that the terms Bright 's disease and chronic ne- 
phritis are so commonly employed synonymously; for Bright 's 
disease, in the modern sense, is a systemic disorder that usually 



CHRONIC NEPHRITIS AND BRIGHT *S DISEASE 205 

produces nephritis, but does not invariably do so, whereas 
chronic nephritis, while often due to Bright 's disease may also 
be due to a great many other causes. 

In Bright 's disease the determining feature is high arterial 
tension, with resulting cardio-vascular changes and nutritionaJ 
disorders in various parts of the body, and, particularly, in 
those organs that are supplied by end-arteries, viz., the kidneys, 
the retina, and the brain. The treatment of this so-called vas- 
cular type of nephritis is therefore practically synonymous 
with the treatment of the cardio-vascular apparatus ; for cardio- 
vascular disorders generally usher in these forms of nephritis 
or appear soon after nephritic signs become apparent; and 
cardio-vascular complications generally produce the death of 
these patients. Cases of this type of nephritis should be treat- 
ed, therefore, more as heart cases than as kidney cases, and for 
this reason the rules of treatment that have been laid down in 
the Chapter on Heart Diseases, particularly in the paragraphs 
on the treatment of valvular diseases of the heart in the stage 
of compensation, apply, broadly speaking, to this type of ne- 
phritis. 

Causal treatment of any variety of chronic nephritis must . 

concern itself primarily with combating or preventing the tox- ment 
emia that, in all probability, produces both the cardio-vascular 
changes and the nephritis. The character of this toxemia is 
still obscure. The preponderance of clinical evidence, however, 
points to a disordered gastro-intestinal tract and liver, on the 
one hand, and to metabolic derangement on the other, as the 
sources of the poisons. Treatment should, therefore, in many 
cases be directed towards correcting any digestive or hepatic 
disorders that may be present. The obscure metabolic perver- 
sions that sometimes underlie the disease unfortunately offer 
nothing very tangible to attack. 

A deranged bowel function leads to the abnormal disassimi- . . 

lation of albumins, chiefly because putrefactive bacteria gain f chronic 
unopposed sway. The toxic albuminoids and alkaloids gener- nephritis 
ated in this way flood the liver channels, where they should 
normally be arrested or disinfected. For a while the hepatic 
cells can withstand the stream of toxic matter that circulates 
around and through them and can properly exercise their dis- 
infecting properties; but an overwhelming mass of putrefactive 
material flooding them at one time, or small quantities of pu- 
trid excrement irritating them continuously, must needs impair 
their function and render them inadequate to protect the organ- 
ism as a whole from poisoning. When this occurs intestinal 



206 



CHRONIC NEPHRITIS AND BRIGHT S DISEASE 



Hepatic insuf- 
ficiency 



Intestinal an- 
tisepsis 



toxins filter through into the circulation beyond, and there can 
exercise their deleterious effect on the heart, on the arteries, and 
also on those organs that chiefly supplement the disinfecting 
function of the liver by eliminating poisons, namely, the kid- 
neys. 

Hepatic insufficiency produced in this way also leads to the 
incomplete elaboration of the afore-mentioned intermediary 
products of metabolism that reach the liver in the general cir- 
culation as poisonous bases, ammonium salts, etc., and should 
leave the liver more highly oxidized as innocuous uric acid, 
urea, etc. When the liver cells are inadequate to produce this 
conversion, then these intermediary bodies are returned un- 
changed to the general circulation, and thus cause auto-intoxi- 
cation. That some of these bodies can produce the cardio-vas- 
cular changes of Bright 's disease, and some of the renal changes, 
was shown by me in 1901/* 

Another important result of hepatic insufficiency is per- 
version of the physical and chemical character of the bile. 
Instead of flushing the bile channels in a broad stream the bile 
sluggishly oozes through the hepatic capillaries. The thick 
and viscid character of the bile favors diapedesis of poisonous 
bile ingredients from the bile channels into the blood capilla- 
ries and besides produces clogging of liver channels, with pres- 
sure on the hepatic cells and on the afferent blood capillaries 
that nourish them; as a result the function of the liver cells 
is still further impaired and self -intoxication is favored. 

Finally the absence of the proper quantity of normal bile 
from the intestine deprives the organism of its most important 
antiseptic secretion, so that intestinal putrefaction increases and 
a vicious circle is in this way closed. 

Causal treatment of Bright 's disease must concern itself, 
therefore, in the first place, with the prevention of intestinal 
putrefaction. Sterilization of the human intestine with its 
thirty feet, more or less, of warm, moist culture medium is man- 
ifestly impossible; nor is it desirable, for many of the micro- 
organisms that normally abound in the bowel aid the enteric 
ferments in the dis-assimilation of the food and produce certain 
physical changes in the bowel contents that favor the act of 
defecation. 

The human intestine is practically sterile at birth; later 
bacteria appear in the bowel contents, some of them pathogenic. 
Against the latter the organism normally protects itself by 



*Croftan — "The Role of the Alloxuric Bases in the Production of the 
Cardio-vascular Changes of Nephritis," Am. Jour. Med. Sciences, Feb- 
ruary, 1901. 



CHRONIC NEPHRITIS ^ND BRIGHT *S DISEASE 207 

very efficient means; when these measures become inadequate, 
artificial intestinal antisepsis is called for. The object of in- 
testinal antisepsis, so-called, is not, therefore, to free the bowel 
from bacteria, but to prevent the pullulation of certain patho- 
genic species and to destroy their poisons. Remedies employed 
to this end may become operative in two ways : They may either 
act chemically by direct contact, or they may act physiologically 
by stimulating the natural defenses of the organism to greater 
activity. 

Most of the drugs employed as intestinal antiseptics fulfill 
both indications, inasmuch as they possess not only germicidal 
properties, but also act as hepatic stimulants. As the liver cells 
possess the power of arresting and of disinfecting many bowel 
poisons, and as the bile is a germicide, any remedy that causes 
increased activity of the hepatic cells and, by inference, acts 
as a cholagogue may be considered an intestinal antiseptic of the 
second variety. 

Chief among the remedies recommended as intestinal anti- Metallic salts 

septics are certain metallic salts, the bile acids and certain or- e aci s 

. . , x . „ . Organic per- 

ganic peroxids. It is necessary, 01 course, that these remedies oxides 

when given in doses sufficiently large to check intestinal putre- 
faction should be non-irritating and non-poisonous. For this 
reason I prefer the sulphocarbolate of zinc to other metallic Sulphocarbo- 

salts (mercurv, lead, silver, copper), and sodium glvcocholate „ a f. ° z \ nc 

• r *^ " & " Sodium glyco- 

to the free bile acids. A variety of organic peroxids under cholate 

various trade names are on the market and I consider them 

useful. 

Intestinal putrefaction may be considered checked when cer- Urinary and 
tain bodies that we know to be formed from the putrefactive d en ce of intes- 
disintegration of albumin disappear from the feces and from tinal putre- 
the urine (abnormal degradation products of the fats and car- 
bohydrates play a subordinate role in auto-intoxication). Chief 
among these are a variety of aromatic sulphur compounds and 
a complex group of substances that also contain the aromatic 
radicles that are split off from putrefying albumin (compound 
glycuronates and compound glycocolls).* 

For clinical purposes it is sufficient to study the sulphids of 
the feces and the aromatic sulphates (with indican as their 
prototype) of the urine. 

The intestinal antiseptics onould be given in small doses Dose an( i a a_ 
( sulphocarbolate of zinc, one-half grain (0.03 gm.) ; sodium ministration 
glycocholate, one grain (0.06 gm.) ; the organic peroxids, one antiseptics 
grain (0.06 gm.), at frequent intervals, together with about 

♦See Croftan : Clinical Urinology, Chapter VII. 



208 



CHRONIC NEPHRITIS AND BRIGHT S DISEASE 



Diet 



The quantity 
of food 



The dangers of 
an exclusive 
milk diet 



twenty grains (1.2 gm.) of bismuth subnitrate in the twenty- 
four hours. The latter is given merely as an indicator of the 
presence or absence of sulphids (sulphureted hydrogen or its 
salts) from the feces. H 2 S or its alkali salts form black bis- 
muth sulphid, and when the intestinal antiseptic is given in 
sufficient quantity to check the putrefaction of albumin, then 
no bismuth sulphid is formed and the stools are not colored 
black. 

It will be found in most cases that when the stools retain a 
light color, despite the administration of bismuth, the indican 
of the urine and the other aromatic urinary ingredients will 
also disappear or become greatly reduced. 

The proper dose, then, of the above-named intestinal anti- 
septics is enough to prevent blackening of the stools after the 
ingestion of bismuth subnitrate and enough to cause the dis- 
appearance from the urine of aromatic bodies. 

The Diet in Chronic Nephritis. In feeding patients suf- 
fering from chronic nephritis three conditions must be fulfilled. 
First, the diet must contain qualitatively and quantitatively all 
that is needed to maintain general nutrition (nutritive equi- 
librium). Second, the diet must contain as little as possible 
of materials that in their ultimate passage through the kidneys 
can irritate the renal epithelia or the glomeruli. Third, the 
diet, while sparing the kidney function, must not overtax or 
otherwise injure the function of the digestive or circulatory or- 
gans. One may say, in a broad sense, that the daily amount of 
food, expressed in caloric values should be inversely propor- 
tionate to the presumable duration of the nephritis. In acute 
forms of nephritis, as we have seen, under-feeding or even star- 
vation of the patient not only is permissible, but is good prac- 
tice; for the smaller the amount of excrementitious bodies the 
kidneys are forced to eliminate the more they are spared and 
the more rapidly can they resume their normal functions. The 
more chronic the nephritis, however, the more nutritive should 
be the diet, so that patients suffering from this disease should 
receive daily the full caloric value in their diet that is required 
to maintain nutritive equilibrium. 

For many years it has been fashionable to feed cases of 
chronic nephritis upon an exclusive milk diet. This method of 
feeding we owe chiefly to the French school of clinicians and 
to numerous imitators that this school has educated, including 
the laity. That milk is a useful article of diet in the manage- 
ment of nephritis, probably the most useful article we pos- 
sess, no one will gainsay. That a milk diet should be given 
persistently and should constitute a large proportion of the 



CHRONIC NEPHRITIS AND BRIGHT *S DISEASE 209 

food to be administered to cases of chronic nephritis is also 
conceded. An exclusive milk diet, however, is directly harm- 
ful and dangerous in chronic nephritis, if carried out for too 
long a time. 

Milk alone cannot maintain the general nutrition for any Deficit of iron 
length of time unless enormous quantities are given. There is m milk 
always, in the first place, a deficiency of one all-important ele- 
ment, viz., iron. In regard to this deficiency of iron, one might 
argue that, as milk can nourish infants for a year or longer, 
the amount of iron in the milk should be sufficient to fulfill all 
the demands of the organism. As a matter of fact, however, i: 
has been demonstrated that milk while it contains exactly the 
same proportion of calcium, magnesium, potassium, phosphorus, 
etc., as the ash of the new born animal of the species from 
which it is derived, contains six times less iron. This anomaly 
is explained by the fact that the iron content of young suckling 
creatures decreases with the age of the animal and reaches its 
minimum at the time when iron-containing food is first eaten. 
The young animal, therefore, brings a surplus of iron into the 
world and is independent of the milk for his supply; but this 
does not apply to adult individuals. Here then, in the first 
place, is a qualitative deficit that must by all means be reme- 
died if an exclusive milk diet is to be given, or even if the 
patient is fed on a diet consisting largely of milk. This is 
best done by adding either chloride of iron solution to the milk 
or by diluting it with iron-containing mineral waters. It is 
not impossible that the lack of iron in the milk contributes in 
part to the anemia that is so common in patients with chronic 
nephritis who become martyrs of an exclusive milk regime. 

The second most important postulate in the proper feeding Excess of nitro- 

of chronic nephritics, viz., to spare the kidnevs, is also violated g^ 11 ? 113 waste- 
products 
if too much milk is given ; for it is a well known fact that albu- 
minous foods by leading to the formation of large quantities 
of nitrogenous end-products, chiefly urea, throw an excessive 
task upon the kidneys ; for urea and its congeners are eliminated 
with difficulty when the kidneys are diseased, and must be con- 
sidered as true irritants of the renal epithelia. It is for this 
reason that we reduce the albumens in the diet of chronic ne- 
phritis ; but if we give enough milk to adequately nourish these 
subjects then we also give an excess of albumen. A normal 
adult requires between two and three thousand calories to main- 
tain full nutrition. As one litre of milk has a total caloric 
value of only about seven hundred, it is clear that from three 
to four litres of cow's milk would be required per diem to meet 



210 



CHRONIC NEPHRITIS AND BRIGHT S DISEASE 



Excess of 
water 



the nutritional requirements of the subject. Such amounts of 
milk contain from one hundred and twenty to one hundred and 
fifty grammes of proteids, whereas the normal average quantity 
required by a healthy adult does not exceed eighty grammes 
per diem; in fact, recent investigations seem to show that ade- 
quate nutrition can very well be maintained on very much less 
albumen. This is particularly the case among individuals whose 
vitality is low and who, as will be shown presently, should lead 
a quiet life with the minimum of physical exercise. 

Finally, if the patient is fed upon milk alone and if enough 
milk is given to adequately nourish him, then too much water 
by far is forced through the cardio-vascular apparatus and the 
kidneys. The danger of stimulating diuresis by abundant water- 
drinking in acute nephritis has already been discussed, and at- 
tention has been called to the danger of trying to forcibly over- 
come the resistance that the diseased kidneys offer to the passage 
of water. In sub-acute forms of nephritis and in those cases 
that are on the border line between sub-acute and chronic ne- 
phritis, the intake of water can be increased; the object being 
to flush out the kidneys and to rid the kidney canals of accu- 
mulated debris. This is a useful practice, because by so doing 
mechanical obstacles to the flow of urine are removed, and the 
work of the kidneys is thereby somewhat reduced. If this pur- 
pose is to be accomplished, however, it is always better to re- 
strict the liquids for a time and then to institute so-called drink- 
ing days, during which very abundant quantities of water are 
ingested. If this is done the renal canals are flushed and at 
the same time accumulated waste products are washed from the 
blood through the kidneys and out of the body. Abundant wa- 
ter-drinking, instituted in this way possibly once or twice a 
month can do no serious damage, whereas abundant water- 
drinking continuously practiced undoubtedly injures the gastro- 
Mineral waters intestinal function, the cardio-vascular apparatus and the kid- 
neys. A warning may incidentally, therefore, be uttered in 
[his place against the indiscriminate use of the many mineral 
.waters that are broadly advertised for the cure of kidney dis- 
eases. 

In the Chapter on Acute Nephritis, the statement was made 
'.hat the water intake should be largely governed by the water 
output. In very chronic forms of nephritis the principle can 
hardly apply for, especially in the interstitial variety of the 
disease, large quantities of water are continuously eliminated 
containing a very small amount of solids in solution. Here, it 
is an easy matter to produce very copious diuresis by copious 
water-drinking, but nothing is gained by this and much damage 



Drinking days 



CHRONIC NEPHRITIS AND BRIGHT *S DISEASE 211 

can be done to the heart and arteries which are particularly 
affected in the latter form of nephritis. 

One other objection to the indiscriminate use of an exclu- Excess of 
sive milk diet may be formulated. It is a well known fact that p osp a es 
phosphates are excreted with difficulty when the kidneys are 
diseased. Milk is very rich in phosphates, and in a healthy 
individual the urinary phosphorus excretion is greatly increased 
on an exclusive milk diet. If the kidneys are to be spared, there- 
fore, the urinary phosphate excretion should be reduced and 
not increased, as is done by feeding milk exclusively. The addi- Addition of 
tion of lime salts to the milk can somewhat obviate this diffi- ^^ water to 
culty, so that in nephritis, lime water should always be added 
to the milk; in this way, calcium phosphate is formed and this 
salt is absorbed with great difficulty from the intestine; con- 
sequently the bulk of the phosphates is excreted in the feces as 
calcium phosphate and is not at all absorbed into the circula- 
tion nor consequently eliminated in the urine. Again, an ex- 
cess of calcium in the milk leads to the formation of chloride 
of calcium in ' the stomach, which is absorbed and combines in 
part with the circulating phosphates, and the latter, it is well 
known, are always excreted, presumably through the bile ducts, 
into the bowel and not through the kidneys into the urine. 

There are still other objections to the exclusive milk diet Disgust and 
that may be briefly formulated as follows : Aside from the }?* s ? f a PP e ~ 
fact that feeding with milk alone, for a long time, becomes thor- elusive milk 
oughly distasteful and even disgusting to the patients, and that ee mff 
consequently the appetite is lost, and the normal psychic stim- 
ulus necessary to perfect digestion is perverted, the ingestion 
of large amounts of water mechanically does injury to the 
stomach and intestine ; for the stomach becomes dilated and the 
gastro-intestinal secretion constantly diluted. This, of necessity, 
impairs the digestive powers of the individual and may lead Gastric dila- 
to a variety of chronic digestive disorders that, as shown above, tatlon 
should be strenuously avoided in chronic nephritis. 

All these objections just formulated apply only to the use 
of excessive quantities of milk in nephritis. If certain pre- 
cautions are observed in regard to restricting the ingestion of 
milk to sensible limits, and if the deficit of iron is remedied by 
the addition of an iron preparation, and if the excess of phos- 
phates is neutralized by the addition of lime water, milk con- 
stitutes a valuable food. Broadly speaking, a case of chronic How to feed 
nephritis should receive from one to one and a half litres of milk 
milk a day; never any more and preferably less. The milk 
should be given in divided doses, at frequent intervals, by 



212 



CHRONIC NEPHRITIS AND BRIGHT S DISEASE 



choice in the form of a milk-cream mixture, consisting of four- 
fifths milk, one-fifth cream and two teaspoonfuls of lime water 
per tumbler full (nine ounces). 

Inasmuch as the function of the liver is frequently pervert- 
ed in chronic nephritis, and the character of the intestinal se- 
Pancreatin and cretion, especially in its upper portions, is consequently changed, 
it is very useful to give after each ration of milk and cream, a 
capsule containing pancreatin and soda, to which may be added 
with advantage the bile acid salts. A gelatine capsule contain- 
ing the following ingredients may therefore be given four or 
five times a day: 



soda 



? 



Pancreas powder, 
Sodium bicarbonate, 
Sodium glychocolate, 
M. 



2 grains (0.12 gm.) 

1 grain (0.06 gm.) 

Y 2 grain (0.03 gm.) 



The kind of 
food and its 
mode of prep- 
aration 



Meats 



As one to one and a half litres of milk contain only about 
600 to 900 calories, this amount of food is not adequate to main- 
tain nutrition, consequently it is necessary to make up the caloric 
deficit by the addition of sufficient proteids, carbohydrates and 
fats to meet the caloric requirements of the individual. The 
rules that should govern the arrangement of the diet, as far 
as the calculation of the caloric values are concerned, have been 
discussed fully in the Chaper on Diseases of Metabolism. 

In selecting the kind of albuminous, starchy and fat food 
to be administered and deciding upon its mode of preparation, 
the following principles should be observed : 

Albumen may be administered in the form of meats, eggs 
or vegetable albumens. Certain meats should be excluded alto- 
gether from the diet, chiefly those that contain extractives and 
toxic principles. To the former class belong all raw, rare, 
smoked, cured and corned meats, for they still contain the ex- 
tractives. Soups, bouillons and meat extracts, as well as most 
gravies, contain the extractives in solution and should be 
strictly eliminated from the diet of a chronic nephritic. In- 
ternal organs, like liver, spleen, kidney, brain, pancreas con- 
tain very abundant nuclein, and as nuclein in process of diges- 
tion is split up into the purin bodies, a group of substances that 
are distinctly toxic and can both . irritate the kidneys and the 
cardio-vascular apparatus, these articles, too, should be excluded. 
In addition, game, which usually contains ptomaines, especially 
if it has hung for some time and has "hautgout," is dangerous. 
Veal is said to be rich in toxic bodies and frequently produces 



CHRONIC NEPHRITIS AND BRIGHT 'S DISEASE 213 

• 

acute digestive disorders, even in well subjects; it ought best, 
therefore, to be eliminated from the diet. Sea foods of all kinds 
should be absolutely fresh, and it would be a sensible rule to Sea foods 
forbid subjects living far from the seaboard to eat any salt 
water fish or crustaceans. To the category of forbidden articles 
also belongs caviar, for it contains a very large amount of nitro- 
gen and an abundance of nuclein, consequently" purin bases, 
and generally some ptomaines. 

There has been much discussion in the literature of recent 
years in regard to the use of light and dark meats. However Light and 
convincing certain purely scientific researches may be that are ar mea s 
intended to show that there is no difference between light and 
dark meats, I have never been able to convince myself that 
it is quite safe to depart from the old empiric rule to reduce 
the ingestion of dark and red in favor of light meats in ne- 
phritis. 

All spices and condiments should be forbidden, for they un- Spices and 
questionably irritate the kidneys. Con imen s 

Eggs were, for a long time, tabooed in nephritis; it seems Eggs 
established that raw eggs increase the albuminuria in certain 
forms of the disease; in view of the fact, moreover, that, espe- 
cially in all large cities, eggs are generally of the cold-storage 
variety, and there is consequently always danger of their con- 
taining ptomaines, they should be eaten sparingly. There is no 
objection, however, to the use of two or four fresh eggs a day. 

Some care should be exercised in the selection of vege- Vegetables to 
tables, thus all vegetables that contain irritating oils or other e av01 e 
pungent principles, like radishes, asparagus and garlic, onions, 
celery should be excluded from the diet. Mushrooms, too, should 
not be permitted; for, in the first place, they contain a very 
large percentage of nitrogen for their bulk; and in the second 
place, as is well known, frequently contain poisonous alkaloids, 
which, even in small quantities, would be particularly dangerous 
in nephritis, because their elimination from the body is in- 
terfered with. All other vegetables may be eaten with im- 
punity. Preference should be given, on account of their su- 
perior nutritive values, to vegetables growing under-ground. 
Salads, too, are very useful, both on account of the slight laxa- 
tive properties that they possess, and because they are usually 
eaten with a dressing containing abundant oil, so that in this 
way considerable fat can be introduced in a pleasant and pal- 
atable form. 

All articles of food made of flour, rice, cereals, may be eaten starchy foods 
with freedom and should be given in abundant quan- 
tities, for they enable the ingestion of a sufficient amount of 



214 



CHRONIC NEPHRITIS AND BRIGHT 'S DISEASE 



Desserts 



Cheese 



Beverages 



Alcohol 



Light wines 



Cordials and 
liqueurs 



Beer 



Tea and coffee 



Cocoa 

Imitation cof- 
fee 



Lemonade 



carbohydrate material and also permit the addition of much 
fat to the diet in the form of butter or cream. This also solves 
the problem of desserts, and patients with nephritis can eat 
puddings, sweets, stewed or fresh fruits, ice cream, etc., with 
impunity. 

Cheese is permissible, with the exception of those varieties 
that contain spices or that are in an advanced stage of putre- 
faction; thus especially Roquefort, Camembert and Parmesan 
cheese should be forbidden. 

A few rules can be formulated in regard to the beverages 
that may be permitted a case of chronic nephritis. The amount 
of liquid permitted has already been discussed above, and the 
relative advantages of drink restriction and abundant water- 
drinking explained. Alcohol should be eliminated, as far as 
possible, from the diet of nephritics, chiefly on account of the 
effect that this drug has upon the cardio-vascular apparatus; 
for, as has been repeatedly mentioned, irritation of the heart 
and arteries and elevation of the blood pressure should be 
avoided in chronic nephritis. If any alcoholic beverage at all 
is to be permitted, and this may be necessary among subjects 
who have been used to a little alcohol all of their lives, then 
light Moselle or Burgundy or Claret diluted with some alkaline 
mineral water may be allowed. Cordials, liqueurs and absinthe 
should be absolutely forbidden, not so much on account of the 
alcohol, but on account of the essences and flavors (aldehydes, 
etc.) that all these beverages contain, and that are excessively 
irritating to the liver and the kidneys. 

Beer is best omitted from the diet of chronic nephritics, espe- 
cially if they are taking large quantities of milk. Among 
subjects who have been used to drinking beer all of their lives, 
the occasional use of a glass of beer can, of course, do no great 
harm, but it is always safer to forbid it altogether. If beer 
is to be taken at all, Stout and Porter are better than German 
beers. 

Tea and coffee are theoretically contra-indicated in chronic 
nephritis. As the withdrawal of these beverages constitutes a 
severe hardship, however, to most persons, a little weak tea or 
coffee thoroughly diluted' with milk may be allowed, especially 
in the morning. One must be governed in the restriction of 
tea- and coffee-drinking somewhat by the individual tastes and 
peculiarities of the case. A very useful beverage, and one that 
can frequently take the place of tea and coffee, is cocoa. Some 
of the imitation coffees, which are black and sweet and hot, 
also have a useful place ; they certainly can do no harm. Lem- 
onade and orangeade are useful beverages, for the citric acid 



CHRONIC NEPHRITIS AND BRIGHT *S DISEASE 215 

they contain is converted into carbonate in the bod} 7 and elim- 
inated as such. 

The importance of withdrawing chlorids from the diet may 
be mentioned in this place. In nephritis the elimination of so- Withdrawal of 
dium chlorid (common salt) is often reduced. It is retained in 
the tissues, and in order to remain there in a solution that 
equals the molecular concentration of the blood and tissue juices, 
it must draw water from the blood (the less concentrated solu- 
tion) into the tissues (the more concentrated solution) by a 
process of osmosis. This idea may in part explain the edemae 
of nephritis. 

On the basis of this theory the ingestion of sodium chlorid, 
i. e., common table salt, has been restricted in order to enable 
the kidneys slowly to eliminate the retained chlorids. If the 
theory were correct the edemas should disappear. 

As a matter of fact, in common with many others I have 
repeatedly seen nephritic edemas disappear (and, incidentally, 
albuminuria decrease) when the chlorids were excluded from 
the food, and reappear when salt was again given. 

As one hundred grains of common salt require about three 
pounds of water to form the proper physiologic solution (i. e., 
a solution exercising the proper osmostic pressure) in the body, 
any sudden increase in the weight of a nephritic patient, other 
things being equal, may mean salt retention and hence water 
retention (deep edemas), and should be an indication, tenta- 
tively at least, to withdraw the chlorids from the food. 

The medicamentous treatment of chronic nephritis is of very Medicamentous 
subordinate importance, for we know of no remedy that can treatment 
exercise a direct effect upon the nephritic process itself. What 
remedies are given should be administered in order to prevent 
constipation and to render the gastro-intestinal tract as nearly 
aseptic as possible (see index), to exercise an effect upon the 
heart's action and the blood pressure and symptomatically to 
relieve drops} 7 and internal edemas. Most of this drug treat- 
ment it will be seen is directed towards improving the condi- Indication? 
tion of the cardio-vascular apparatus ; it is in all essentials iden- or rugs 
tical with the treatment described at length in the Chapter 
on the Heart and Arteries. The symptomatic treatment of 
renal dropsy differs in no way from that of cardiac dropsy (see 
page 42). Drugs that can be given to relieve symptoms about 
the stomach, the lungs and the central nervous system are 
either discussed in the Sections on Gastro-intestinal or Pul- 
monary Diseases or in the Chapter on Uremia. It is useless, 
therefore, to describe all these remedies again in this place. 



216 



CHRONIC NEPHRITIS AND BRIGHT ? S DISEASE 



Necessity of 
giving 1 drugs 
sparingly 



Hydrotherapy 



Effect on 
heart's action 
and blood 
pressure 



Physiology of 
blood pressure 



Changes in 
peripheral re- 
sistance 



Drugs should, at all events, be used sparingly in chronic 
nephritis, for the continuous administration of drugs is always 
fraught with many inconveniences. In the first place the pro- 
longed use of medicine is bound sooner or later to injure those 
organs that are concerned with their absorption and elimination, 
notably, the stomach, the liver and the kidneys ; and in addition 
the effect of most drugs that we might give for the sake of re- 
ducing the blood pressure or stimulating catharsis or diaphore- 
sis is exceedingly transitory and the organism soon becomes ac- 
customed to them. 

It is much safer to undertake symptomatic treatment by 
hydro-therapeutic means, for, if the patient has been treated 
largely by such measures, then he always has drugs to fall 
back upon in emergencies should alarming symptoms develop 
that require energetic treatment. And as a rule it will be found 
that much smaller doses of the different medicines will be re- 
quired in such cases to produce the desired effect than in pa- 
tients who have been habituated for long periods of time to 
the use of cardiac tonics, vaso-dilators, cathartics, diuretics, dia- 
phoretics, etc. This is a great advantage. 

Hydro-therapy is the most efficient means for influencing 
the heart's action and the blood pressure. Three elements en- 
ter into the physiology of arterial tension, viz., the amount of 
the blood, the force of the contraction of the heart, and the de- 
gree of peripheral resistance. From the heart emanates the 
force that propels the blood into the arteries and causes the 
tension of their walls. The peripheral resistance, by creating an 
obstacle to the evacuation of the arteries, causes an accumula- 
tion of the blood in these vessels and tension of their walls with 
a reactive elastic pressure that propels the blood onward. The 
mass of blood finally is the intermediary agency that driven 
from behind and compressed from in front distends the arteries 
to such a degree that the elastic powers of their walls can be- 
come operative. Increased or decreased, these three factors de- 
termine variations in the blood pressure, and all three factors 
can be profoundly influenced by hydriatic measures. 

Changes in the peripheral resistance can be brought about 
both by cold and by hot applications. In chronic arterial dis- 
eases the latter, however, should have the preference, for this 
reason: The application of cold always at first produces a 
contraction of the peripheral vessels, followed very shortly by 
a dilatation called "the reaction." This physiological reaction 
that leads to reduced blood pressure cannot be utilized with 
safety in most cases of chronic nephritis; (1), because the pri- 
mary contraction of the peripheral vessels causes a sudden in- 



CHRONIC NEPHRITIS AND BRIGHT 'S DISEASE 217 

•crease of the arterial tension and may, in predisposed subjects, 
produce rupture of the weakened blood vessel walls in the brain, 
the retina or otherwise; (2), because the cold causes an increase 
of the heart's action by a nervous reflex that is transmitted 
directly to the cardiac ganglia; (3), because, in chronic ne- 
phritis, the reaction may fail altogether owing to lack of tone 
or possibly to anatomic changes in the musculature of the peri- 
pheral arteries, or on account of myocardial changes. 

The method of choice, therefore, for reducing the peripheral Hot hydriatic 
blood pressure is the application of heat to the body surfaces, cold 
for hot applications, provided the degree of temperature is not 
too high, produce from the beginning cutaneous hyperemia 
without preceding contraction of the peripheral blood vessels, 
and if continued, true relaxation of the muscular coats of the 
peripheral arteries with a corresponding fall in the blood pres- 
sure. Moreover, heat causes a long-lasting loss of tone on the 
part of the peripheral blood vessels, in other words, a prolonged 
vaso-dilator effect, whereas the reaction following cold appli- 
cations leads to what may be called a tonic congestion of the peri- 
pheral vessels during which the tone of the blood ves- 
sels is fully preserved so that contraction soon follows. Heat, 
furthermore, if applied for a sufficient length of time produces 
dilatation not only of the cutaneous vessels, but also of the deep 
blood vessels; whereas, the dilatation of the superficial vessels 
produced by cold is usually accompanied by intense contrac- 
tion of the deep vessels, an effect that leads rather to high than 
to low blood pressure. The fall of blood pressure, therefore, 
following hot applications is much more permanent and its pro- 
duction fraught with less dangers than the decrease of arterial 
tension produced by cold or by medicinal vaso-dilators. 

The simplest way of applying heat to the surfaces of the Hot baths 
body for the purpose of reducing blood pressure is to give the 
patient what may be called a ''hot soak," i. e., the patient is 
instructed to once or twice a day (for practical purposes best 
•early in the morning and late at night) lie perfectly still for 
five or ten minutes in a bathtub filled with water a few degrees 
"below the temperature of the body. If it is desired to increase 
the effect friction may be applied for a time by an attendant 
while the patient is immersed in the bath. 

The addition of a few pounds of salt to the water, or im- Salt or car- 
mersion in warm carbonated water, is very useful because the 5°?^ c acid 
salt and the carbonic acid both assist in relaxing the peripheral 
•capillaries. The bathroom should always be kept very warm The bathroom 
for the capillaries of the skin are relaxed after the bath and 
should be kept so as long as possible ; if the- room is cold sud- 



218 



CHRONIC NEPHRITIS AND BRIGHT S DISEASE 



Danger of col- 
lateral hy- 
peremia 



Cold to the 
head 



Effect on vol- 
ume and com- 
position of the 
blood 



Electric light 
and hot air 
baths 



Danger of 
sweating by 
dry heat 



den contraction of the cutaneous vessels occurs and therewith a 
rapid rise of blood pressure and an increased strain upon the 
heart — all effects that one is precisely trying to avoid. In 
cases, moreover, in which the vaso-motor tone is below par, and 
this is common in cardio-nephritics, there is always considerable 
danger of catching cold. The best plan of all is to have the 
patient lie down in a warmed bed for a time after the bath. 

One other important point must further be considered in 
using this plan, viz., the occurrence of collateral hyperemia in 
various parts of the body, especially the brain. For this reason 
the head should always be covered with cold cloths or an ice 
bag during all the time the patient is in the water. It will be 
found that this plan not only reduces the blood pressure for 
many hours thereafter, but also slows the heart and reduces the 
force of its contractions. Occasionally the rapidity of the heart 
action is slightly increased, especially after the patient leaves 
the bath. In such cases the application of the ice bag to the 
precordial region, or of cold cloths to the nape of the neck, may 
be employed to reduce the number of heart beats. 

A marked effect can further be exercised by hydro-thera- 
peutic measures upon the composition and the volume of the 
blood. From all that has been said above, it is clear that cold 
applications are absolutely contra-indicated in any case of ne- 
phritis owing to the sudden initial rise of blood pressure and the 
nervous shock to the heart that they engender. It is useless, 
therefore, to discuss in this place the interesting effect that cold 
applied to the surfaces of the body can exercise upon the per- 
centage of leucocytes and of red corpuscles, and upon the 
specific gravity and the volume of the blood; and we will con- 
cern ourselves therefore exclusively with the use of hot applica- 
tions in order to see what effects, that may be beneficial in ne- 
phritis and that we usually attempt to produce by drugs or 
diet, can be produced by heat. 

Dry heat, i. e., the electric light bath or hot air, applied in 
different ways, always produces a greater concentration, i. e., 
a decrease in the total volume of the blood. This is due, of 
course, to the loss of water through the sweat glands, and while 
this practice by accelerating the current of lymph may act bene- 
ficially in the absorption of edemas, I have never been satisfied 
that sweating produced in this way is beneficial in cases of ne- 
phritis without edemas; for while some solids are lost through 
the sweat glands, the loss of water is immeasurably greater, 
and the concentration of the blood is so much increased by this 
practice that whatever toxic bodies may be circulating can un- 
doubtedly exercise a more deleterious effect in a concentrated 



CHRONIC NEPHRITIS AND BRIGHT 'S DISEASE 219 

than in a diluted form. The reduction of the blood pressure 
that might result from a decrease in the volume of blood is off- 
set by the greater toxicity of the circulating fluids, for the 

pressor principles they contain are not eliminated via the sweat Copious water 

drinking* dur- 
glands. If dry heat is applied, then the patient should at all i ng . the sweat 

events at the same time be given very copious draughts of 

water to compensate for the loss of water by diaphoresis, but 

as this practice undoubtedly throws a great strain upon the 

heart and arteries that have to pump this water from the 

stomach to the emunctories of the body, I have always felt that 

the benefits accruing from sweating by dry heat are more than 

neutralized by all these disadvantages. 

For this reason if sweating is to be produced at all it should Sweating by- 
be done by means of moist heat, and here the method moist heat 
of choice is without doubt immersion for five, ten or fifteen min- 
utes in water heated slightly above the temperature of the 
body. It will be found that when this plan is adopted, the con- 
centration of the blood does not increase, as manifested by de- 
terminations of its specific gravity, freezing point, and electric 
conductivity. It is possible, as Wick has suggested, that the 
loss of water through the sweat glands is compensated by the 
absorption of water from the tissues, superinduced and aided 
by the pressure exercised from without by the water of the 
bath; at all events, immersion in hot water, aside from lower- 
ing the blood pressure by prolonged vaso-dilatation, causes a 
certain loss of excrementitious solids through the sweat glands 
without causing great concentration of the body fluids, in other 
words, greater toxicity of the latter, and without consequently 
necessitating the administration of much water by mouth. If 
properly carried out immersion in hot water really aids the body 
in getting rid of both solids and water with safety. 

In all diseases complicated by high arterial tension and an Hydriatic 
irregular and excitable heart action, and to this category belong means to allay 

'• ■ 11 n * i -. • • • • n '' nervous un- 

practically all cases 01 chronic nephritis, it is a matter of great tability 

importance to allay the nervous irritability. We should always 
endeavor to do this psychically by quieting the patient's fear, 
trying to keep him from worrying about his condition, and ad- 
vising him not to lead too strenuous a life, and we usually en- 
force this effect by sedative remedies. Much more can be accom- 
plished in this direction with complete safety by hydro-thera- 
peutic means. This fact is so well-established that nowadays Psychic treat- 
the standard treatment of neurasthenia, and of many psychoses ment 
complicated with excitement, consists in the use of hydro- 
therapeutic means. As a rule it is impossible to carry out such 
treatment at home. Certain simple measures that a^e of great 



220 



CHRONIC NEPHRITIS AND BRIGHT 7 S DISEASE 



Effect of hy- 
driatic means 
on the general 
metabolism 



Effect on di- 
gestion 



value in quieting the sensibility of the whole nervous system, 
including the vaso-motor nerves, can, however, be carried out in 
one's house, and chief among these, again, is the use of warm 
water and, by preference, the prolonged warm bath. 

Upon the general metabolism the use of hot water also exer- 
cises a very profound influence that is particularly valuable in 
nephritis. For immersion of the body in hot water for some 
time, by preventing the loss of heat by radiation, and, inci- 
dentally, by causing dilatation of the blood vessels supplying 
the muscles, causes an acceleration of metabolism, particularly 
of the non-nitrogenous constituents. This is a valuable effect 
in nephritis as it prevents to a certain degree the accumulation 
of waste products in the blood and relieves the kidneys of the 
necessity of excreting them. In obese subjects a considerable 
loss of fat can be brought about in this way, especially when 
judiciously combined with proper exercise treatment, and that 
this is invaluable in any form of cardio-renal disease need hardly 
be emphasized. 

The use of dry heat is again not safe on account of its effect 
upon metabolism, because the body at once consumes an in- 
creased amount of its own nitrogenous constituents to make up 
for the loss of heat by radiation; in this way flooding of the 
blood stream with urea and bodies that are intermediary be- 
tween albumen and urea is brought about. Whenever this oc- 
curs increased labor is thrown upon the kidneys, as they must 
rid the organism of this circulating waste material. 

Upon the digestion, i. e., upon the secretory and motor func- 
tion of the stomach and bowels, hydriatic procedures also 
exercise a profound influence. Unfortunately, however, the 
measures that are most efficacious in promoting increased secre- 
tion and improved motility are cold hydriatic means, and these 
we cannot employ. The one cold measure that is useful and 
that can be applied with safety is the application of cold locally 
over the liver, either in the form of a Priessnitz compress or by 
means of a cold stream of water directed against the hepatic 
region with the rest of the body protected. This process stimu- 
lates the hepatic function and promotes an increased flow of bile. 
In view of the presumably hepatic origin of many forms of 
Bright 's disease (see page 206), this is a useful adjuvant to treat- 
ment, especially since the entrance of much bile into the upper 
portion of the bowel reduces intestinal putrefaction. This is 
one of the most desirable effects that can be obtained in nephritis, 
an effect that we usually attempt to bring about by dietetic and 
medicinal means. 



CHRONIC NEPHRITIS AND BRIGHT 'S DISEASE 221 

In conclusion a word should be said in regard to the effect of Effect on the 
hydriatic procedures upon the flow of urine. Cold applied to ow ° urme 
the surfaces of the body, as is well known, stimulates diuresis 
both by raising the blood pressure and presumably also by a re- 
flex action upon the musculature and the sensory nervous appar- 
atus of the bladder. This becomes manifest by the almost in- 
stantaneous desire to urinate that patients develop as soon as 
cold measures are applied. As cold is inadvisable in nephritis, we 
cannot make use of this procedure, but I do not consider this a 
disadvantage, for I have never been convinced that the stimu- 
lation of diuresis is a desideratum in nephritis. Any measure 
that increases the flow of urine by implication stimulates, even 
irritates, the kidneys, immaterial whether the stimulus be a 
drug acting directly upon the secretory mechanism of the kidneys 
or upon the blood pressure within the kidneys. When the kid- 
neys become diseased they at once fail, as shown above, to elim- 
inate certain bodies properly, but to force them to eliminate, 
nevertheless, is a precarious procedure for it violates one of the 
fundamental principles of the treatment of a functionally inad- 
equate organ, viz., that this organ should be rested rather than 
irritated and forced to work. For rest alone will enable Nature 
to institute the necessary reparative processes and to hasten re- 
covery. Consequently heat is again useful for it lowers the 
blood-pressure in the kidneys and consequently may somewhat 
reduce diuresis, but it also spares the kidneys by soothing rather 
than irritating the nervous apparatus that superintends the man- 
ufacture and excretion of urine. 

It will be seen, therefore, that such simple measures as hot signal ad- 
bathing, properly administered, and the application of hot or van tages of 

& ' * * J ' ** proper hydro- 

cold to various portions of the body, can accomplish much in the therapy in the 

treatment of the nervous, metabolic, gastro-enteric and cardio- chronic n ne°n- 
vascular manifestations of nephritis that we ordinarily attempt ritis 
by drugs. 

In selecting a climate its effect upon the skin should be con- Climate and 
sidered, preference should be given to a climate in which the 
daily temperature fluctuations are very small, in which the alti- 
tude is low and the atmosphere dry; for such a climate stimulates 
insensible perspiration, so that the kidneys are relieved of some 
of the labor of excreting water; moreover, the surfaces of the 
body are not alternately heated and chilled, consequently there 
is less danger of catching cold and less probability of disturbing 
the vaso-motor equilibrium and hence causing congestion of the 
diseased kidneys. Otherwise the choice of a resort or a climate 
should be governed by the condition of the heart and arteries 
(see page 24). In Europe, chronic nephrotics are sent to Egypt, 



222 



PYONEPHROSIS AND PYELITIS 



Exercise 
Massage 



Surgical 
treatment of 
Bright's dis- 
ease 



Algiers, Corsica and the Riviera. In the United States, Southern 
California, Arizona and New Mexico furnish the most ideal loca- 
tions for this class of cases. 

The regulation of exercise and the administration of massage 
likewise are dependent on the state of the cardio- vascular appar- 
atus more than of the kidneys. For a discussion of this part of 
the treatment I refer, therefore, to the Chapter on Diseases of 
the Circulatory Apparatus. 

One word may be said in conclusion concerning the so-called 
surgical treatment of Bright 's disease. Splitting of the kidney 
capsule, or decapsulation of the organ, for the cure of Bright 's 
disease is altogether irrational. The temporary relief of tension 
may improve the blood supply to the kidneys, and hence restore, 
i'or the time being, some functional activity to diseased epithelia ; 
nrid this improvement in the renal function may become mani- 
fest by a reduction of the edema, by a transitory decrease in. the 
albuminuria, the disappearance of formed elements (casts, etc.) 
from the urine, and an increase in the excretion of solids and of 
water. Bright 's disease, however, as we have seen in the pre- 
ceding paragraphs, is a systemic disorder and the nephritis 
is merely one of its symptoms. Any treatment of the kidneys 
alone, whether surgical or otherwise, is, therefore, purely symp- 
tomatic, and can in no sense be regarded as curative. One might 
as well amputate the rose spots in typhoid fever and expect to 
cure the disease. It is not surprising to find, therefore, that no 
true case of Bright 's disease has even been permanently bene- 
fited by operations on the kidneys. The procedure is mentioned 
in this place merely to be condemned. 



Causal and 

prophylactic 

treatment 



II. PYONEPHROSIS AND PYELITIS. 

Pyonephrosis and pyelitis are rarely primary disorders. As 
a rule they are consecutive either to calculus disease, or they 
develop by ascending infection from some disorder of the lower 
genito-urinary passages. Occasionally they are blood-borne as, 
for instance, in tuberculosis, typhoid, pneumonia, scarlet fever, 
diphtheria and small-pox. Carcinoma and sarcoma, and occa- 
sionally syphilis, also produce pyelitis, possibly by weakening the 
resistance of the tissues and thus rendering them susceptible to 
infection. 

The causal and prophylactic treatment of pyelitis must take 
all these pathogenetic elements into consideration. Thus in some 
cases the same rules apply as in the treatment of nephro-lithiasis, 
disorders of the bladder, urethra and female genitalia. Treat- 
ment directed towards preventing pyelitis in infectious diseases 



PYONEPHROSIS AND PYELITIS 223 

consists in promoting a copious diuresis and advancing every 
effort to reduce the toxicity of the urine and increasing the re- 
sisting powers of the renal and pelvic tissues. The inflammation 
within the renal pelvis can be favorably influenced by the appli- Counter-irrita- 
-cation of leeches or cups over Petit 's triangle, i. e., that area petit's tri- 
which is bounded by the crest of the ilium, the latissimus dorsi an S le 
And the external abdominal oblique muscles, for the veins of 
this region connect directly with the veins of the renal capsule, 
so that counter-irritation, bleeding or cupping over Petit's tri- 
angle can exercise an important effect upon congestion within 
.and around the kidney. In addition the bowels should be kept Catharsis 
freely open by the use of laxatives, preferably of a vegetable 
character. In this way revulsive action is promoted and at the 
.same time the absorption of bowel toxins that might be irritating 
to the kidneys in their passage into the urine prevented. 

The diet should be bland and non-irritating and consist Diet 
largely of milk. Here the principle of sparing the kidney that 
is so important in most renal disorders of an acute and sub-acute 
•character, obtains with particular force, for the kidneys must 
be enabled to put forward every effort towards combating the 
local inflammation. The diet should consequently be arranged in 
the same way as outlined under Acute and Subacute Nephritis. 
There is one exception to this rule, viz., cases of pyelitis without 
nephritis should always drink plenty of water in order to dilute 
the urine and thus flush the kidney channels and the pelvis, 
prevent ascending infection and stagnation and mechanically, in 
•case the presence of calculi is suspected, promote their expulsion. 

In the latter case, provided it is possible to determine the 
composition of the concretions from fragments that may be 
passed or from other urinary signs, the same dietetic rules should 
be observed as described under Xcphrolitliiasis. 

In the more chronic varieties astringents, chiefly tannigen, in Astringent? 
doses of from ten to thirty grains (0.6 to 2 gm.), or catechu, 
preferably in the form of the compound catechu powder, con- 
taining catechu, kino, krameria, cinnamon and nutmeg, in doses 
of from ten to seventy grains a day (0.6 to 2.4 gm.) may be given. 

In this disease, finally, urinary antiseptics have the widest Urinary anti- 
field of application. Best of all is urotropin, which may be given se P tlcs 
in doses of from three to ten grains (0.2 to 0.6 gm.) in a full 
glass of water, three or four times a day. Benzoate of soda, in Urotropin 
doses of from five to thirty grains (0.3 to 2 gm.) in water; the Sod i um ben " 
oil of copaiba, in doses of from ten to fifteen minims (0.6 to 1 cc.) Copaiba 
in capsules; the oleum cadinum (empyrheumatic oil of juniper) Juni P er 0l1 
in the same doses, are all useful. 

Finally, salol, in doses of from five to fifteen grains (0.3 



224 



LAVAGE OF THE RENAL PELVIS 



Salol 

Sod. sulpho- 

carbolate 

Methylene blue 



Pain 



Surgical treat- 
ment 



lntra-pelvic 
medication 



to 1 gm.) in capsule or powder or, the sulphocarbolate of sodium 
in from five to fifteen grain (0.3 to 1 gm.) doses three or four 
times a day can also be employed. Methylene blue is without 
effect. All of these remedies should be taken with abundant 
water and in using any of them great care should be exercised 
not to produce renal irritation. Their prolonged use is, as a rule,, 
somewhat dangerous, hence the urine should always be carefully 
examined for casts or other evidence of nephritis. As soon as 
such signs appear the administration of these drugs should be 
interrupted or stopped. 

The pain in pyelitis should be treated in the same manner 
as the pain in nephrolithiasis and renal colic (see page 232). 

In cases of very severe suppuration that do not yield to 
medicamentous treatment, combined with the proper diet, hy- 
giene and rest, surgical intervention may become necessary, con- 
sisting in drainage of the kidney, removal of concretions that 
may be present, or even nephrectomy. 

Of recent years still another method of treating pyelitis has 
been devised, consisting in the introduction of a ureteral catheter 
and the injection of various astringents and antiseptics directly 
into the renal pelvis. 



THE TREATMENT OF PYELITIS BY LAVAGE OF THE RENAL PELVIS. 



Instruments 
employed 



Technique 



(By Dr. F. Kreissl, Chicago.) 

Lavage of the renal pelvis is performed by injecting medi- 
cated fluids into the pelvis through a ureter-catheter, introduced 
by means of a cystoscope. The direct or indirect view catheter- 
izing-cystoscope may be employed. In the male the direct view 
cystoscope no doubt causes more tension and traumatism to the 
prostatic urethra than the indirect view instrument. The former,, 
also, will be found inadequate where the ureteral os, as quite 
frequently happens, is located close to the vesical sphincter. On 
the other hand it will generally be found that the passing of 
the catheter into the ureter is more readily accomplished with 
the direct view cystoscope, for here the curve from the instru- 
ment to the ureteral os is eliminated. For the purpose in ques- 
tion a cystoscope should be employed which can be removed 
without disturbing the position of the catheter in the renal 
pelvis. The catheters used should have moderately blunt points, 
and should be introduced without undue haste in order to avoid 
traumatism. Renal lavage, if carried out carefully, and under 
strictly aseptic precautions in every detail is a harmless pro- 
cedure. 



LAVAGE OF THE RENAL PELVIS 225 

The solutions most commonly employed are a warm solu- Solutions em- 
tion of boric acid, 4 to 100; oxycyanide of mercury, 1 to 4000: y 
nitrate of silver, 1 to 2000 to 1 to 1000 ; protargol 1 per cent, and 
argyrol, 5 to 20 per cent. Of the silver solutions mild concen- 
trations should be used at first, gradually increasing their 
strength from treatment to treatment. 

The quantity to be injected must vary with the capacity of Quantity to be 
the renal pelvis in each individual case ; however, so much should mj 
never be injected as to cause over-distension and colicky pains. 
In the majority of cases I have found injections of 4 to 8 cc. at 
a time sufficient. 

The intervals that should elapse between each application de- Frequency of 
pend on the nature and the extent of the local trouble. If there applications 
is much debris in the renal pelvis it will be necessary to perform 
preliminary irrigation with a warm boric acid solution until the 
fluid returns fairly clear, and then to inject the antiseptic ; while 
in cases with little pus in the urine, the antiseptic may be de- 
posited at once without a preceding cleansing irrigation. 

Where the conditions require daily renal lavage in male Leaving the 
patients I always prefer leaving the catheter in situ for a few catneter m 
days at least ; this permits frequent topical application without 
unnecessary and inevitable traumatism to the prostatic urethra 
incident to repeated introduction of the instrument. 

The extravagant claims which have been made for this Limitations of 
method of treatment are not supported by facts, but it cer- tne method 
tainly has a definite, though limited, sphere of usefulness. To 
appreciate this the following points may be considered : Etiolog- 
ically pyelitis, or rather pyelonephritis, is more frequently 
caused by a descending or hematogenous, than by an ascending 
or urogenous, infection. If the suppuration be of hematogenous 
origin, the kidney parenchyma must have been first infected, 
and it is hard to understand how a topical application to the 
renal pelvis can effectively reach the focus in the kidney proper. 
And the same objection must reasonably be made to the efficacy 
of the method in the ascending type of pyelonephritis. At best 
one can expect some relief of those symptoms which are due to 
abnormal conditions in the renal pelvis and are directly trace- 
able to the infection and inflammation existing in that locality as, 
e. g., retention of pus and urine arising from inflammatory swell- 
ing or blocking of the ureteral openings, renal colic from dis- 
tension of the pelvis and fever. 

Cases of suppurative pyelitis without involvement of the Suppurative 
kidney proper constitute only a small fraction of the cases of P velitis 
pyelitis that come under observation ; this is partially explained 



226 



NEPHROLITHIASIS 



Complications 



Spontaneous 
healing of un- 
complicated 
pyelitis 



Gonorrheal 
pyelitis 



Renal lavage 
not effective in 
mixed infec- 
tions 



Summary 



by the generally accepted fact that hematogenous infection is 
the more common cause of pyelitis than urogenous infection ; per- 
haps also by the absence or the mildness of perceptible symptoms 
in initial stages of the disease that render its early discovery 
rare. This also explains the fact why we do not often see cases 
before the kidney parenchyma has been invaded. 

Another point to be considered is that many of these cases 
either are caused by or complicated with calculus, malforma- 
tions of the renal pelvis, strictures or other obstructions in the 
ureter and urethra, tuberculosis, tumors, etc., so that renal 
lavage can, at best, give only temporary relief, while suitable 
and well directed surgical measures will usually obviate the 
necessity of any topical application. 

Furthermore, the vast majority of uncomplicated cases of 
pyelitis heal spontaneously, or under the use of the internal 
agents discussed in previous paragraphs of this section. Almost 
the only exceptions to this rule are ascending gonorrheal in- 
fections of the renal pelvis. These eases are not so rare as is 
commonly believed and they do not yield to conservative treat- 
ment, while renal lavage with efficient silver solutions has gen- 
erally given me surprisingly good and rapid results. Fre- 
quently, however, especially in older cases the gonococcus ap- 
pears associated with bacterium coli, staphylococcus and other 
germs; if properly treated the gonococcus in such cases dis- 
appears permanently from the renal pelvis, but I have never 
succeeded in a single case of this kind in clearing the urine thor- 
oughly or permanently of the other bacteria. This leads me to 
the conclusion that renal lavage is not effective in mixed in- 
fections of the pelvis, or else that the gonococcus has a tendency 
to locate in the pelvis, while the other germs invade the kidney 
proper where topical applications do not reach them. 

Summing up my experience with renal lavage in many cases 
of divers types of pyelitis and pyelonephritis, I recommend its 
use as a curative agent in pyelitis uncomplicated by nephritis, 
stones or strictures, and then only when the ordinary means of 
internal medication fail to remove the suppuration. 



Indications for 
treatment 



III. NEPHROLITHIASIS. 

The treatment of nephrolithiasis must concern itself, first, 
with preventing the deposit of concretions in cases that are pre- 
disposed to the formation of renal stones; second, with facili- 
tating the passage of the concretions after they have once 
formed; third, with preventing secondary infections and, lastly, 



NEPHROLITHIASIS URICA 227 

with symptomatically relieving the pain, the renal colic, the 
hematuria and other phenomena. 

The prophylactic measures that we can employ vary accord- Prophylaxis 
ing to the character and the composition of the urine. Thus 
an individual voiding an acid urine, with occasionally a little 
gravel or sand composed of uric acid, urate or oxalate crystals, 
must be treated differently from a subject whose urine is alka- 
line and possibly purulent; for, in the latter, we have every 
reason to dread the formation of phosphatic deposits. Of the 
many concretions that can form in the urinary passages the most 
important varieties, and those that, alone, in the light of our 
present knowledge, are amenable to causal and prophylactic 
treatment, are uric acid and urates, oxalates and phosphates. 



NEPHROLITHIASIS URICA. 

To prevent uric acid or urate deposits the solubility of the Four factors 
urinary acid must be increased ad maximum. The factors that sohibinty r ?f ne 
chiefly* determine this solubility are the concentration of the urinary uric 
urine, the percentage of uric acid it contains, its content of 
sodium chloride and above all its reaction. The more concen- 
trated the urine and the more uric acid and sodium chloride it 
contains percentically the greater the tendency to the precipi- 
tation of nric acid and urates in the urinary passages. 

For these reasons the urine should always be rendered dilute 
by abundant ingestion of water; the urinary excretion of uric 
acid should be reduced as much as possible by proper dietetic Diet 
and medicinal means, as described in full in the Chapter on 
Diseases of Metabolism (page 177), and, finally, the intake of 
sodium chloride, i. e., of common table salt, should be restricted. 

The most important element in the prophylactic treatment of 
nephrolithiasis urica, however, is the regulation of the reaction 
of the urine, for it is a well established fact that the alkaline 
urates are more soluble than acid urates or uric acid itself. To Alkalies 
render the urine less acid and to promote the solubility of uric 
acid, alkalies, i. e., chiefly sodium carbonate and bicarbonate, or 
alkaline mineral waters, are commonly given in nephrolithiasis 
urica. It must be remembered, however, that the action of alka- 
lies in cold urine, or even in normal urine, as studied in the 
test tube, differs materially from their effect on a highly con- 
centrated urine, such as we find it in nephrolithiasis urica, in 
which the gravel deposits at body temperature. The changes in 



*Iu all forms of nephrolithiasis there must also be a cementing ma- 
terial (mucus fibrin, pigments, etc.) that makes a concretion out of a 
fine sediment. 



NEPHROLITHIASIS URICA 



Effect of alka- 
lies on propor- 
tion of dif- 
ferent urinary- 
phosphates 



The decrease 
of phosphoric 
acid in the 
urine 



Calcium as a 
remedy 



the reaction of the urine, moreover, that are seen after the admin- 
istration of alkalies must be interpreted with great care if 
urinary titration methods are employed, for here many sources 
of error creep in that need not however be discussed in this place. 

The most important influence undoubtedly exercised by the 
administration of alkalies upon the solubility of uric acid in 
the urine is the change in the relative proportion of acid, neu- 
tral and basic phosphates in the urine that they bring about. 
For uric acid is readily soluble in basic phosphates (di-sodium 
phosphate), but insoluble in acid phosphates (mono-sodium phos- 
phates) ; the addition, in fact, of mono-sodium phosphate to a 
solution of uric acid in di-sodium phosphate will cause the pre- 
cipitation of uric acid. It is clear, therefore, that the solubility 
of uric acid in the urine is enhanced by the presence of di- 
sodium phosphate, and that the tendency to the formation of 
uric acid concretions increases in proportion to the amount of 
acid phosphate that is excreted through the kidneys. It is also 
clear that any effort directed towards preventing the precipi- 
tation of uric acid in the urinary passages must be concerned 
with increasing the amount of basic, and decreasing the amount 
of acid, phosphates. The ideal would be to cause the complete 
disappearance from the urine of mono-phosphate and, at the 
same time, to produce an elimination through the kidneys of a 
4uantity of di-phosphate sufficiently large to hold all the uric 
acid excreted in solution. This can be accomplished in two ways, 
viz., either by decreasing the phosphoric acid in the blood that 
enters the kidneys or by increasing the sodium in this blood. 
The latter object can be accomplished by sodium salts but better 
still, as will be presently shown, by calcium salts. 

To decrease the phosphoric acid its source must be consid- 
ered; it may be derived from preformed phosphates ingested 
with the food or from the phosphorus contained in the albumins 
(chiefly nucleins) of the food or the body tissues proper that is 
converted, by intra-cellular oxidation, into phosphoric acid. By 
eliminating from the diet, on the one hand, pabulum containing 
preformed phosphates or nuclein-containing food, and by re- 
moving, on the other hand, from the blood and tissues, through 
other channels than the kidneys, the phosphoric acid that must 
inevitably be formed from the degradation of our own tissues, ^ 
we can reduce the urinary phosphate excretion. 

We possess a remedy that can both directly and indirectly 
regulate the phosphoric acid content of the blood and hence of 
the urine, viz., calcium salts.* For, in the first place, calcium 



*Croftan: The Use of Calcium Salts in Nephrolithiasis, etc. Jour. 
A. M. A., 1904. 

*See Croftan: "Clinical Urinology." 



NEPHROLITHIASIS URICA 229 

forms insoluble salts with the alkaline phosphates contained in 
our normal food, and in this way prevents the absorption of this 
moiety into the blood. In the second place calcium, owing to 
the great affinity it possesses for phosphoric acid, combines 
with the phosphoric acid encountered in the blood stream, and 
causes the elimination of this proportion in the form of calcium 
phosphate — not, however, through the kidneys, but in great 
part through the intestine. This is an important point, for, 
in contradistinction to sodium, potassium and magnesium, all 
elements that are chiefly eliminated through the kidneys, cal- 
cium is principally (85 to 95 per cent.) eliminated through the 
bowel. 

It will be seen, therefore, that calcium given by mouth can, Mode of action 
first, prevent the entrance of a certain proportion of preformed of calcium 
phosphoric acid (phosphates) from the food into the blood, and 
can, secondly, prevent some of the phosphoric acid formed in 
the organism from passing into the urine by causing its elimina- 
tion through the intestine. 

In order to increase the sodium (or potassium) in the renal Dangers of 
blood, sodium (or potassium) salts, as stated above, are com- ^°^ 1 ?^ e ^ D al " 
monly administered ; but this practice is not without its dangers, 
for it may produce alkalinization of the urine and therewith 
create a tendency to the formation of x>hosphatic deposits (see 
below) upon the uric acid or urate stones. When this occurs 
the concretions usually grow rapidly and more harm is done 
than good. Whenever an alkali therapy is employed, therefore, 
care should be taken above all things to keep the urine faintly 
acid. This is difficult when sodium (or potassium) salts are 
given for long periods of time; their continued use, moreover, 
exercises a deleterious effect upon the gastric digestion and is 
not without effect upon the corpuscular elements of the blood. 
Calcium salts, on the other hand, never render the urine alkaline Advantages of 
and are fully as efficacious as sodium or potassium salts for they, calcium salts 
as shown above, cause a illative increase of the sodium and 
potassium and hence of the sodium (potassium) di-phosphate 
of the urine. They are, therefore, the best prophylactic reme- 
dies in nephrolithiasis, either alone or in combination with small 
quantities of sodium carbonate and, above all, with plenty of 
water. 

The best calcium preparation is the carbonate. This may be 
given in doses of fifteen to twenty grains, three times a day. Dose and ad _ 
More may be given with impunity. It is necessary to individ- ministration 
ualize. The smallest efficient quantity of any drug is always salts 
the best dose. The urinary calcium, phosphorus and uric acid 
excretion can to advantage be determined in the beginning (the 



230 



NEPHROLITHIASIS URICA 



Mineral wa- 
ters containing 
calcium 



Uric acid 
solvents 



Fallacy of giv- 
ing" uric acid 
solvents 



Lithium 



patient being on a fairly constant nuclein-free diet) and the 
dosage regulated accordingly. 

A more convenient method of administering calcium, and 
one that is preferred by most patients, particularly if the treat- 
ment is to be carried out indefinitely, is to give calcium in the 
form of natural mineral waters or as an addition to some pure 
water. Among the better known European mineral waters Con- 
trexeville, Wildungen and Fachingen contain the largest propor- 
tion of calcium salts. Among domestic waters the choice is diffi- 
cult. The exploiters of the majority of them make such blatant 
and extravagant claims in regard to wonder cures that it is not 
safe to place any reliance on this essentially commercial propo- 
ganda. Personally, I prefer adding the necessary amount of 
calcium salt or lime water to some pure water. 

A word may be said in this connection in regard to certain 
other remedies that have been recommended from time to time 
as so-called uric acid solvents. In most cases these remedies are 
given because they possess the property of dissolving uric acid 
in the test tube. One is not justified in deducing from this fact 
that they can also dissolve uric acid in the body, especially after 
urates have crystallized out or concretions have once formed. 

This applies with particular force to the alkalies that have 
just been discussed. They do not possess the power of dissolving 
urate concretions in the renal passages or otherwise in the body, 
but they act prophylactically by increasing the solubility of the 
circulating acid and preventing its deposit. They may also act 
beneficially by promoting general oxidation, and they finally 
possess a certain diuretic effect which is useful. 

It is preposterous to give alkalies or any other remedies with 
the idea that they will dissolve urate concretions. One might as 
well give ether to dissolve the fat of the body in obesity, or min- 
eral acid to dissolve the calcium out of osteophytes, on the ground 
that ether or acids can dissolve fat or calcium salts in the test 
tube. The amount of ingested alkali, moreover, that actually 
reaches the uric acid deposits (which are usually covered with 
a thin layer of mucoid material that protects them from " sol- 
vents") is so small that a solvent effect can impossibly be 
accomplished. 

This criticism applies with particular emphasis to lithium 
preparations that are so popular in the treatment of uric acid 
diseases. In the first place so-called lithia waters contain only 
a few decigrammes of lithium carbonate to the litre. As they 
always also contain large quantities of other alkalies only a very 
minimal amount of uric acid (according to Barthollet's law) 
would at best combine with the lithia, the bulk with the sodium 



NEPHROLITHIASIS URICA 231 

and potassium salts, while, at the same time, most of the lithium 
would be promptly excreted as chloride, phosphate and sulphate. 
Finally, lithium carbonate, which actually does readily dissolve 
uric acid in the test tube, is immediately converted in the 
stomach into lithium chloride, a salt that possesses only slight 
uric acid dissolving properties. 

Other preparations that have been recommended as uric acid Lysidin, sido- 
sol vents are lysidin and sidonal (the quinic acid salt of piper- nal > piperazin. 
azin). I have never been able to convince myself that either of 
these remedies exercise any solvent effect whatsoever in nephro- 
lithiasis urica. Urea too is considered a uric acid solvent, and it urea 
actually possesses the power to a very marked degree of dis- 
solving uric acid outside of the body. Clinically, however, the 
results obtained from the administration of large amounts of 
urea have been, on the whole, unsatisfactory. What beneficial 
effect it occasionally exercises in ridding the renal passages of 
small concretions must presumably be attributed to its marked 
diuretic action. Benzoic acid in the form of sodium benzoate, in Sodium ben- 
doses of five to thirty grains (0.3 to 2 gm.) in water has been zoate 
extensively used. It does not dissolve urate concretions, but it 
acts as a urinary antiseptic and hence may prevent infection 
of the urinary passages, with disagreeable secondary conse- 
quences like pyelitis. Other urinary antiseptics have been dis- 
cussed in the part on Pyelitis. 

Urotropin (hexamethylentetramine) is probably the only rjrotropin 
remedy that in a measure has vindicated its claim to being a 
uric acid solvent in nephrolithiasis. It splits off formaldehyde 
in the body and the latter combines with uric acid to form a 
soluble compound. It has also been shown that the urine of 
patients who have taken large doses of urotropin acquires the 
power to a marked degree of dissolving uric acid. Urotropin is, 
besides, a very effective urinary antiseptic, so that it truly de- 
serves extended trial in nephrolithiasis urica. It should be given 
in five to ten grain doses, in a full glass of water, two or three 
times a day. 

One of the most useful remedies to promote the expulsion Glycerin 
of concretions that we possess, aside from diuretics and abundan t 
water-drinking, is glycerin. It should be given in large doses of 
50 to 100 cc, in lemonade or water. Its mode of action is not 
well understood, but symplomatically it certainly sometimes aids 
in the expulsion of small concretions. The urine should, how- 
ever, always be carefully examined for evidence of renal irrita- 
tion, for in certain subjects glycerin produces hematuria; so that 



232 



NEPHROLITHIASIS URICA 



Olive oil 

The relief of 
renal pain 



Heat and cold 



Local applica- 
tions of tur- 
pentine and 
belladonna 

Opium 



Chloral hy- 
drate 



Chloroform 



Renal hem- 
orrhage 



Ergot 

Erigeron 
Tannigen 

Hydrastis 

Surgery 



as soon as blood appears in the urine, the administration of 
glycerine should be stopped. Olive oil, too, has been used for 
this purpose. 

For relieving the pain in nephrolithiasis either heat or cold 
or counter-irritants may be applied to the lumbar region. In 
the dull pain that is so characteristic of a large stone, heat is 
usually more grateful than cold, whereas in the acute paroxysm 
of pain in renal colic, cold usually affords greater relief than 
heat. 

Turpentine or tincture of belladonna (a few drops on flannel 
wrung out of hot water) applied locally in the lumbar region 
help the dull ache, but exercise no effect upon the colic. 

In severe renal colic opium will usually have to be given, 
either hypodermically as morphine, in doses of one-fourth to 
one-half grains, or by rectum in the form of a suppository or a 
starch enema. Chloral hydrate, ten to twenty grains (0.6 to 1.2 
gm.) by rectum, also frequently relieves. The patient can to 
advantage also be placed into a warm bath or into bed with hot 
water bags to the lumbar region. If these simple measures fail 
to bring relief, then a few whiffs of chloroform will occasionally 
not only stop the colicky pain, but actually facilitate the passage 
of the calculus by producing relaxation of muscular spasm. 

Eenal hemorrhages, if slight, should be treated by rest in 
bed, while the bowels are thoroughly evacuated and the patient 
is kept on a milk diet. At the same time certain drugs may 
be given, especially if the hemorrhage becomes obstinate and 
very severe. The most useful drugs are the fluid extract of ergot 
in fifteen to thirty drops (1.0 to 2.0 gm.), or preferably the 
injection of ergot hypodermically, using ergotin, one part, and 
camphor water, two parts, in doses of three to ten drops (0.15 
to 0.65 gm). The oil of erigeron, fifteen to thirty drops (1.0 to 
2.0 gm.) in capsule may be used if there is no nephritis. Tan- 
nigen, ten to thirty grains (0.6 to 2.0 gm.) in powder; th^ 
fluid extract of hydrastis, fifteen to sixty minims (1 to 4 cc), or 
better the hydrochlorate of hydrastinin, given hypodermically or 
by mouth, in doses of one-half to two grains (0.03 to 0.1 gm.) 
repeated, are all useful remedies. 

In case the medicamentous and dietetic measures, combined 
with rest, fail to stop the pain and hemorrhage; if the attacks 
of renal colic persist or if severe suppurative pyelitis com- 
plicates the disorder ; or, finally, if a calculus becomes impacted 
in a ureter so that the patient's life is endangered from mechan- 
ical anuria, then recourse must be had to surgical means. 



NEPHROLITHIASIS OXALURICA 233 



NEPHROLITHIASIS OXALURICA. 

Uric acid and oxalic acid are chemically closely related. Relation of 

There is also a peculiar relationship between dextrose and oxalic oxalic a <; id t0 
. _ , . , n ' . . uric acid and 

acid that is not altogether understood; clinically we know, at dextrose 

all events, that many cases of mild diabetes develop oxaluria and, 

chemically, we know that dextrose can be converted into oxalic 

acid. 

The diet consequently should be arranged in such a way Diet 
as to take into consideration both the factors that may determine 
increased uric acid secretion and glycosuria. Besides all articles 
of diet should be excluded from the bill of fare, or greatly 
reduced, that contain preformed oxalic acid. Chief among the Articles of 
latter are tea, cocoa, spinach, gooseberries, rhubarb, figs and i n ^ d oxalic^ 11 " 
pepper; in addition, coffee, chocolate, chicory, red beets and acid 
tomatoes, the last named articles, however, containing only very 
small quantities. Champagne and beer also seem to lead to an 
increased oxalic acid excretion. In cases, moreover, that show 
a decided tendency to oxalate deposits, sugar, sweets, cereals, 
vegetables growing underground, and all starchy foods should be 
reduced. 

Meat (with the exception of nuclein-containing organs, i. e., special articles 
raw, rare and cured meats, meat extracts and bouillons), eggs, of diet 
green vegetables, salads, plenty of milk and fat, in any form, 
should constitute the chief articles of diet. In addition much 
water should be taken, preferably between meals, on rising and 
on retiring. The addition of a little soda to the water, or drink- ^drSkixJ*" 
ing alkaline mineral waters, is a useful adjuvant to the treat- 
ment. 

As many cases of nervous dyspepsia, chiefly hyper-acidity of P epJia U and yS " 
the stomach, seem to develop oxaluria, particular attention should oxaluria 
always be paid to this condition according to the rules that are 
discussed in another chapter. 

The symptomatic treatment of oxaluria is the same as that treatment 1C 
previously discussed under the heading of Nephrolithiasis Urica. 

NEPHROLITHIASIS PHOSPIIATICA. 

Phosphate concretions occur only when the urine is alkaline. Etiological 
As a rule they form upon a pre-existing urate or oxalate calculus, rea men 
•or upon some organic debris in the kidneys, the pelvis, the 
ureters or the bladder. Phosphate concretions are consequently 
most commonly found in inflammatory, purulent disorders of the 
urinary passages, particularly if there is some stagnation of 
urine. Treatment, especially in this form of nephrolithiasis, 



234 



FLOATING KIDNEY 



Diabetes 
phosphatide 



Muriatic acid 



Phosphoric 
acid 



Symptomatic 
treatment 



should hence be directed principally towards rendering the urine 
aseptic, towards preventing its stagnation and towards com- 
bating the existence of pyelitis or cystitis, according to the 
methods spoken of in appropriate sections. Phosphate stones 
cannot be dissolved by any known means after they have once 
formed. 

There is also an indistinct metabolic perversion which leads 
to an increased excretion of phosphorus, so-called Diabetes Phos- 
pkaticus, in which basic phosphates are excreted in great excess. 
This, in the obscurity of our present knowledge, we are unable 
to influence. 

An attempt should always be made in phosphate lithiasis to 
render the urine less alkaline and this can best be done by admin- 
istering by mouth muriatic acid (Acid Hydrochlor. dil. — dose 
five to thirty drops in water t. i. d.), or, paradoxical as it may 
sound, phosphoric acid (Acid Phos. dil. — dose five to twenty 
drops, twice or three times a day in water). 

The symptomatic treatment of pain, colic, hemorrhage, etc., 
and the indications for surgical intervention are the same as in 
other forms of nephrolithiasis. 



Causes 



Interpretation 
of the symp- 
toms of float- 
ing kidney 



IV. FLOATING KIDNEY. 

Unless the dislocation of the kidney is due to trauma or 
spinal curvature, abnormal motility and abnormal location of 
the organ are generally a part symptom of a general gastro- and 
enteroptosis. Floating kidney is found much more frequently 
in women than in men. This is due to a number of causes ; the 
wearing of corsets and tight waistbands ; pregnancy with result- 
ing sudden changes in the intra-abdominal pressure; dislocation 
of the uterus and its adnexa exercising a direct pull by continuity 
upon the ureters and kidneys. The right kidney is more fre- 
quently dislocated than the left, both in men and women, first, 
because it is normally somewhat more motile than the left; sec- 
ond, because the left renal artery is shorter than the right and is 
more intimately connected by the suprarenal vein with the 
suprarenal gland than on the right side ; third, because the pan- 
creas gives some support on the left side, and, fourth, for the 
reason that tight lacing is more apt to loosen the right than the 
left kidney, as on the right side the solid and unyielding liver 
lies between the waist and the kidney, whereas on the left side 
the hollow stomach forms a yielding and elastic cushion that 
does not transmit the pressure exercised from above. 

In the great majority of cases the increased motility of the 
kidney per se makes no symptoms. In some of the cases the 
general gastro- and enteroptosis may produce a variety of dis- 
tressing phenomena that are often, though falsely, attributed to 



FLOATING KIDNEY 235 

the floating kidney. In still other cases, and these form the ma- 
jority, a general neurasthenic state exists, either altogether inde- 
pendent of the abdominal conditions or possibly remotely de- 
pendent upon the digestive disorders and the abnormal traction 
or pressure on the nerve plexuses that the abnormal position of 
the various abdominal viscera, including the kidneys, produces. 

From a therapeutic standpoint slight degrees of floating kid- Therapeutic 
ney are a negligible quantity; whatever treatment may be di- mdlcatlons 
rected towards the general symptoms of the patient should be 
directed more against the abdominal ptosis than against the float- 
ing kidney as such. Whenever symptoms are produced, how- 
ever, that are directly traceable either to a tugging of the kid- 
ney on its attachment, or to twisting of the pedicle of the kidney, 
with resulting congestion of the organ and possible hydro- 
nephrosis and pain, then special treatment of floating kidney 
becomes necessary. 

In view of the mechanical conditions existing the remedy The remedy 
must needs also be mechanical and directed towards causing a must °e me - 

chanical 
restitution of the kidney to its normal position and holding it 

there. Occasionally rest in bed in a recumbent position for weeks 
at a time, especially combined with a Weir Mitchell fattening 
treatment (see index) may lead to an increase of the abdominal 
fat and hence furnish a support for the movable kidney. There Rest and fat- 
is no evidence to show that this plan leads to the formation of tenm §' cure 
a new fatty capsule around the kidney, nor is there for all that 
any proof that in floating kidney the fatty capsule is lost. The 
plan is particularly useful however in thin, neurotic women, both 
because in these cases the increase of the abdominal fat and th.- 
resulting greater tension of the abdominal walls really supports 
the kidneys in conjunction with the other abdominal viscera, and 
because the rest-cure and the over-feeding act beneficially 
towards restoring nervous equilibrium. The result is that these Results of rest 
patients frequently arise from the rest and "Mast" cure with a cure 
kidney that is still somewhat motile but with a nervous system 
whose tone is restored to such an extent that it is no longer 
irritated by the abnormal excursions that the kidney occasionally 
undertakes. 

The use of pads and bandages is rarely of lasting benefit in 
the treatment of floating kidney and is generally disagreeable p a d s and 
to the patients. If any support is to be applied at all it should bandages 
be a general abdominal supporter intended to hold up all the 
abdominal viscera, possibly with a pad or pelotte, besides, below 

the kidney region. When this is done, the disagreeable symptoms General ab- 

dommal sup- 
that are attributed to the floating kidney, but that in realitv, as porter 



236 



Constipation 
and gastric 
distension to 
be combated 



The clothing- 



Indications for 
surgical treat- 
ment 



Relief of acule 
symptoms 



stated above, usually arise from the general abdominal ptosis, are 
frequently relieved. 

Care should always be taken that constipation, over-loading 
of the stomach and congestion of the liver are carefully coun- 
teracted by proper dietetic and medicinal means; for when this 
is done, the weight of the abdominal organs is reduced and less 
dragging permitted. The clothing should properly be worn sus- 
pended from the shoulders and not fastened about the waist. 
Lacing, of course, should be forbidden. 

If the degree of dislocation is so severe that the kidney occa- 
sionally becomes twisted, with resulting hydro-nephrosis and con- 
gestion of the organ with urinary signs that point to degener- 
ation and functional disturbances in the renal epithelia, or if 
the kidney becomes very sensitive to pressure or hurts sponta- 
neously, then, after all the other means have been tried, surgical 
intervention becomes justifiable ; but not before. 

There is unfortunately, nowadays, an exaggerated tendency 
to operate upon the floating kidney in cases of general abdominal 
ptosis; and while the operation rarely does any harm in this 
condition, and may occasionally even do good through the ben- 
efits derived from enforced post-operative rest in bed and proper 
feeding, still, a cure by surgery should never be promised nor 
the operation advised unless symptoms directly attributable to 
the kidney become unbearable, or unless nephritic changes in 
the dislocated organ make their appearance. A description of 
the operative technique lies without the limits of this article. 
In most cases a simple nephrorrhaphy is the operation of choice. 

The acute symptoms produced by twisting of the renal pedicle 
must be relieved by hot applications and morphine, with rest in 
bed, while attempts are made at the same time to correct the 
temporary dislocations of the organ by manipulation, if neces- 
sary under an anesthetic. 



Critique of 
current uremia 
theories 



V. UREMIA. 
In order to properly treat uremia it is essential to have a 
clear understanding of the causes that determine pre-uremic 
states and the uremic attack, or, as one might also express it, 
chronic, and acute uremia. Uremia is commonly considered to 
be due exclusively to inadequacy of the renal function, with 
resulting retention of excrementitious urinary bodies. If this 
current belief were correct, then complete anuria should always 
produce uremia, and the blood of uremic patients should always 
show an increase, and the urine a corresponding decrease, of 
urinary substances. , _ ^ 



UREMIA 237 

As a matter of fact, many cases of complete anuria, due to Anuria does 

various causes, are recorded, in some instances persisting for n ot always 

. . produce uremia 

several weeks, in which none of the characteristic phenomena 

of uremia developed. On the other hand, uremia not unfre- 
quently occurs when the flow of urine is abundant and the excre- 
tion of urinary solids and water does not appreciably deviate 
from the normal. Similar results are seen in animals after 
experimental nephrectomy or occlusion of both ureters, or after 
the injection of urine. The animals die, but are not uremic. 

One must, therefore, distinguish, clinically at least, between 
uremia and urinemia. In uremia we witness the signs of Uremia and 
urinemia but also other signs besides. The latter, precisely, are urmemia 
the most characteristic symptoms of uremia and never occur in 
urinemia. This alone forces one to the conclusion that they must 
be produced by other factors than simple urine poisoning, a con- 
tention that is borne out by an analytical study of the blood 
and urine in uremia. 

Without going into the analytic data in detail the statement 
may be made that quite as many cases of uremia develop without 
as with an abnormal amount of nitrogenous or saline constit- 
uents in the blood. There also is much chemical and clinical Metabolic dis- 
evidence to show that in uremia the general metabolism and, in or er 
particular, the manifold functions of the liver, are perverted. 
Moreover we not infrequently encounter a condition of acidosis Acidosis 
that points to a severe auto-intoxication that cannot be attri bated 
to renal inadequacy alone.* 

That the kidneys are not always primarily involved is further The kidneys 
borne out by the clinical observation of an occasional case of pri m arTly y ln- 
uremia in which the kidneys are found practically normal after volved 
death, and in which essentially no evidence of renal disease, or 
even of functional inadequacy on the part of the kidneys, pre- 
sented itself during the life of the patient. 

This newer conception of uremia must induce us to depart 
from the orthodox method of treating uremia. 

We are wont to treat uremia by promoting vicarious elim- The orthodox 
ination, i. e., by stimulating the flow of urine, by purging and hernia and° its 
by sweating, with the intention or relieving the kidneys of the fallacies 
work of excreting retained urinary bodies. Occasionally we 
even attempt to force these bodies through the damaged kidneys 
by using diuretic drugs. In addition, we try to regulate the 
diet in such a way that there shall accumulate in the blood the 
smallest possible amount of residual excrementitious bodies. If, 



♦For the details, see Croftan, "An Analytic Study of Uremia." Jour. 
A. M. A., January 6, 1906. 



238 



Prophylaxis of 
uremic attacks 



The diet in 
chronic uremia 



Carbohydrates 



Alkaline wa- 
ters and al- 
kalies 



Hepatic stim- 
ulants 



Calomel 



Bile acid salts 



Salol 



Warm bathing 



now, uremia is not clue to the circulation in excess of such bodies, 
nor to renal inadequacy alone, then the above treatment is 
wrongly directed. 

The chief object in chronic uremia, i. e., in pre-uremic states, 
should be to prevent the development of uremic attacks, i. e., 
of acute uremia, by giving attention to those organs whose func- 
tions threaten to fail; and in order to do this intelligently the 
renal idea should be somewhat relegated to the background and 
more attention should be bestowed upon the liver and the general 
metabolism. 

In chronic uremia the diet should be arranged in such a way 
that the function of the liver is not overtaxed; at the same time 
the existence of a chronic nephritis should be included in the 
calcu]ation. A diet consisting largely of milk and carbohydrate 
foods is the ideal. In view of the chronic character of the dis- 
order care must, however, above all things, be taken that ade- 
quate nutrition is maintained, and for this reason the addition of 
some albuminous food, preferably in the form of vegetable albu- 
mens, is very desirable. Carbohydrates possess a high nutritive 
value, and at the same time exercise a gentle stimulating effect 
upon the functions of the liver, without, coincidently, leading to 
the formation of end-products that irritate the kidneys in their 
passage. Alkaline waters are also very useful in this condition, 
for they too gently stimulate the liver, and, above all things, 
counteract the tendency to acidosis which not infrequently ap- 
pears in chronic uremia, as manifested by the increased ammonia 
excretion in the urine. Calcium carbonate, in fifteen grain doses 
three or four times a day, in powder or capsule, is a useful means 
to aid in maintaining alkalinity. 

The use of hepatic stimulants is also indicated, although great 
care should be exercised not to give remedies that can irritate 
rather than stimulate the liver; thus calomel I consider a dan- 
gerous drug in chronic uremia. Bile acids, preferably in the 
form of sodium glycocholate, in doses of one-fourth to one-half 
grains (0.0015 to 0.003 gm.), together with five to ten grains 
(0.3 to 0.6 gm.) of sodium carbonate, half an hour after eat- 
ing, are useful. They possess a distinct cholagogue action and 
also act as intestinal antiseptics. Salicylates, preferably in the 
form of salol, in one grain (0.006 gm.) doses, together with an 
alkali, three or four times a day, half hour after eating, act 
similarly and are also useful. 

In chronic uremia warm bathing is an excellent preventative 
measure. "The patient should be instructed to lie quietly, for five 
or ten minutes, in a tub of water slightly below the body tem- 
perature, with a cold cloth applied to the head to prevent reactive 



UREMIA 239 

hyperemia of the brain. Such a bath should be given every 
evening and may, to advantage, be followed by an alcohol rub, 
«are being taken that the bath-room is warm and the patient 
does not take cold. This measure is very effective in reducing 
the blood pressure and in preventing acute uremia. If threat- 
ening cerebral signs of uremia appear, a hot bath, combined with 
friction of the surfaces of the body, is a useful means for abort- 
ing convulsions, and the patient, in uremic coma, may safely be 
placed in a hot bath while cold water is poured upon the head, 
provided the other means described below for combating acute 
uremic seizures are instituted at the same time. 

Chronic uremia principally manifests itself in a protean Symptomatic 
array of symptoms involving nearly every organ of the body, treatment 
While every endeavor is being put forward to treat the conditions 
thai, underlie uremia, it becomes necessary in addition to insti- 
tute symptomatic treatment for the relief of disagreeable sub- 
jective symptoms. In view of the fact that, in uremia, Nature Gastro-intes- 
puls forward every effort to promote vicarious elimination of tinal symptoms 
ace u ululating toxins through the different emunctories of the 
body, disagreeable symptoms about these organs, that are due 
largely to their irritation by the poisonous bodies that are clam- 
oring for elimination, occasionally require special treatment. 
Thus vomiting and diarrhea are very common symptoms in 
chronic uremia. In addition the heart is very frequently over- Heart svuid- 
stimulated and ultimately becomes fatigued, so that failure of toms 
the heart muscle makes its appearance with edema and stasis; 
these phenomena, too, occasionally require special treatment. 
Finally, cerebro-spinal uremia, of a chronic type, occasionally 
appears, presumably due either to edema of the central nervous Cerebro-spinal 
tissues or to irritation of these nerve elements by circulating urenua 
toxins that have a selective affinity for certain nervous tissues. 
The symptomatic treatment of these various uremic phenomena 
may now be discussed seriatim. 

Vomiting in uremia must, as a rule be regarded as an Vomiting 

endeavor on the part of the organism to rid itself of circulating 

poisons by way of vicarious emesis, and it is questionable whether 

it is good practice to check this vomiting at once. Vomiting 

may occasionally even be stimulated to advantage by giving the 

patients lukewarm water to drink. Only when the vomiting when to 

becomes so severe that the patients cannot retain any food, or check vom- 

if the heart and arteries, and, in particular, the cerebral vessels 

threaten to become seriously over-strained, or if the patients 

cannot sleep, should we actively interfere by giving symptomatic 

relief. For this purpose, we can use oxalate of cerium, in doses __„... 

Oxalate of 
of from two to ten grains (0.1 to 0.6 gm.), frequently repeated, cerium 



240 



Tincture of 
iodine 



Chloroform 
Cocaine 

Ice 
Lavage 

Diarrhea 



Saline laxa- 
tives 



Opium. 
Tannin 



Cardio-tonic 
medication 



Edema 



Pulmonary 
edema 



Atropine 



This remedy acts like bismuth, but is less toxic and frequently 
stops the nausea and vomiting. Or the patient may be given 
from one to three drops of the tincture of iodine in ice cold 
water or in a few ounces of cold milk. Chloroform, in doses of 
from five to ten drops, or a dilute solution of cocaine as described 
elsewhere, may also be given to advantage. If none of these 
means is efficacious, then the swallowing of small pieces of ice 
and the application of cold over the epigastric region may occa- 
sionally stop vomiting, and sometimes, in extreme cases, lavage 
of the stomach leads to the goal. 

Uremic diarrhea, which is often troublesome, should always 
at first, be encouraged; that is, a complete evacuation of the 
gastro-intestinal tract should be promoted by the administration 
of saline laxatives, for here we must again assume that the organ- 
ism is trying to get rid of irritating poisons by the bowel path. 
Saline laxatives are also advantageous in cases of uremia with 
failing heart and venous stasis and edema of the bowel wall, for 
the withdrawal of water from the edematous tissues by the saline 
acts beneficially. If the diarrhea persists so long that the nutri- 
tion of the patient is interfered with, then attempts should be 
made to check the bowel movement by the use of opium or tannin ;. 
the former given, preferably, as laudanum, either by mouth, in 
doses of from five to fifteen drops, repeated every hour or so 
until the desired effect is produced, or by rectum in thirty to 
sixty minim doses, preferably in starch enema and also repeated. 
Tannin is probably best given as tannigen (diacetyltannin), in 
doses of ten to twenty grains (0.6 to 1.3 gm.) repeated until effect. 

The heart is usually seriously affected in uremia, and cardio- 
tonic medication, as described in the Chapter on Heart Diseases, 
becomes necessary. Uremic edemas in various parts of the body 
are often due to cardiac failure and they should be treated pri- 
marily by cardio-tonic medication (see index). One of the 
most dangerous forms is edema of the respiratory tract, vjz., 
pulmonary edema and edema of the glottis. Here very active 
measures must at once be instituted if the life of the patient is 
to be saved, and energetic sweating and purging becomes neces- 
sary, even occasionally stimulation of diuresis with the main 
object in view, irrespective of anything else, of ridding the 
organism as rapidly as possible of the accumulated water. Atro- 
pine in doses of one one-hundredth to one one-hundred-and- 
fiftieth of a grain hypodermically, , may be administered if 
the patient threatens to drown in his own secretions. In edema 
of the glottis, ice applied to the neck and ice swallowed are useful. 
If necessary, scarification of the edematous laryngeal folds or 



UREMIA 241 

<3ven tracheotomy may be resorted to. In pulmonary edema cold 
or mustard plasters to the chest also occasionally relieve. 

Uremic asthma is best treated by the use of ether given as Uremic asthma 
spirits of ether, in doses of ten to thirty drops several times a 
day; or in the form of pure ether, hypodermically, in doses of 
1 to 2 cc, or by mouth, in teaspoonful doses, three or four times Ether 
during the twenty-four hours. If this treatment, which inci- 
dentally stimulates profuse diuresis, does not relieve the asth- Valerian 
matic seizure, then tincture of valerian, in doses of one to three Oxygen 
drachms (5 to 10 cc), oxygen inhalation, or a few whiffs of ° orm 

chloroform must be tried. 

As stated above it sometimes becomes necesary in chronic vicarious elim- 

uremia to stimulate vicarious elimination with the expectation m ation 

that together with much water some toxic material may also be 

eliminated, and in this way a purification of the blood and tissue 

juices be brought about. . A very useful measure is to stimulate 

the action of the saliva^ glands, and a case of chronic uremia 

should be advised to chew gum. For the sake of producing 

catharsis, very mild laxatives or dilute laxative water should stimulation of 

be used, remembering always that no drug that can irritate the salivary 

glands 
liver should be used, for this organ, as we indicated above, is 

commonly involved in the chronic uremic self -intoxication. 

Sweating,* if advised at all, should always be combined with 
water-drinking or the use of large, water enemas ; for unless this Sweating 
is done a concentration of the body fluids will be brought about 
and the intoxication be rendered more severe. An acute uremic 
attack, in fact, may be produced by injudicious sweating, partic- 
ularly as the blood, when it becomes concentrated by sweating 
without the simultaneous introduction of water, draws abundant 
toxic material from the edematous tissues in which the toxins are 
deposited and carries the poisons in a concentrated form to the 
higher nervous centres. 

Diuresis is best stimulated by digitalis combined to advantage D . 
with caffein (see formula, page 43), by the copious ingestion of 
hot water, preferably slightly alkaline, and by large alkaline — 
saline enemas. 

The treatment of the acute uremic attack is always an un- The treatment 

grateful task, for immaterial whether we are dealing with a dis- of the ac ^ te 

uremic attack, 
order that is primarily or in its ultimate consequences due 

to renal, hepatic or general metabolic insufficiency, we are in 
most cases concerned with a syndrome that is due to the crum- 
bling of the whole cellular edifice. To arrest this collapse essen- 
tially means to revive a dying organism. That this may occa- 



*See page 237. 



242 



CYSTITIS 



^Bleeding 



Infusion of 
physiological 
salt solution 



TyTarcotics 



Chloral 
enemas 



TJrethan 



Xumbar punc- 
ture 



sionally be done, for the time being, cannot be denied; and as 
the recuperative powers of the human body border on the phe- 
nomenal no effort should be spared to bring an acutely uremic 
patient back to life. 

The acute attack usually sets in with fulminating symptoms 
simulating epileptic seizure (uremic eclampsia) and gradually 
leading to coma, occasionally preceded by a severe headache or 
a syndrome that resembles the aura of epilepsy. 

The appearance of cerebral uremia, manifesting itself by 
severe headache, neuralgia, psychic disturbances, insomnia, 
twitchings, amaurosis, etc., is usually a grave danger signal, 
generally constitutes a premonitory warning of an impending 
uremic attack and should be fought most energetically. Bleed- 
ing is the sovereign remedy, carried out as described on page 
37. A considerable quantity of blood, if need be a quart, should 
be withdrawn. A uremic attack may often be prevented in this 
way. If large quantities of blood are withdrawn, venesection 
may be followed to advantage by the infusion of an amount of 
warm, sterile, physiological salt solution (0.8 gm. to 1000 cc.) 
corresponding to the quantity of blood abstracted. 

The symptoms about the nervous system unfortunately, as 
a rule, cannot be controlled by any other drugs than narcotics, 
i. e., morphine or opium. Occasionally enemata, containing 
ten to fifteen grains of chloral, repeated every two hours, or 
inhalations of chloroform, become necessary. Urethan also is 
useful here, given 4 by rectum in watery solution in large doses, 
i. e., about five drachms (about 20 gm.) in twenty-four hours. 
In severe spinal manifestations lumbar puncture should be 
done. It will often be found that the fluid in the cerebro- 
spinal canal stands under high pressure, and symptomatic 
relief is frequently obtained by drawing it off, thus 
reducing this pressure. Lumbar puncture possibly also 
relieves by withdrawing fluid that contains much toxic 
material in solution from intimate contact with irritable 
nervous tissues. 



VI. DISEASES OF THE BLADDER AND URETHRA-CYSTITIS. 

(By Dr. F. Kreissl, Chicago.) 
Definition ^ n the treatment of cystitis, irrespective of any conventional 

classification, we have to bear in mind that the disease is merely a 
symptom of some underlying pathological lesion, that every true 
cystitis is of mycotic origin and that "simple cystitis 7 ' is only a 
theoretical condition. 



CYSTITIS 243 

Since the mode and avenues of the infection have become Prophylaxis 
better known and since it has become established that trauma- 
tism and infection by instruments is one of the most frequent 
contributing causes of cystitis, much has been accomplished in 
the way of prophylaxis. This source of infection can be and is 
successfully eliminated by extreme cleanliness, asepsis and anti- 
sepsis in everything that comes in contact with the urethra, in 
cleansing of the latter preceding and following the use of in- 
struments, in preventing stagnation of urine in the bladder, and 
in exercising better care of the urinary tract during labor and 
gynecological operations. 

The principal indications for the treatment of cystitis are: Indications for 

1. To remove the cause treatment 

2. To relieve pain and frequent urination. 

3. To modify the character of the urine so as to make it 
an unfavorable medium for the development of pathogenic 
microbes, and 

4. To check suppuration. 

In the acute stage, as in many other local inflammations, Rest 
rest in bed should be insisted upon until the symptoms are well 
under control. The food should be bland and should consist Diet 
largely of fluids in small quantities, milk, or milk mixed with 
Vichy being preferable. The still customary ingestion of large Liquids 
quantities of fluids in cystitis should be discouraged, as it only 
increases the congestion of an inflamed organ which is much in 
need of rest. Careful attention should be given to the bowel. 
A purge of calomel and pulverized jalap, 0.10 of each, followed Purgation 
by a wineglassful of magnesia citrate answers the purpose. 

A hot Sitz bath of 105° F., if necessary repeated several sitz bath 
times daily, will afford much immediate relief to the pain and 
tenesmus. Hot fomentations applied to the perineum and above Fomentations 
the pubes are almost as efficient; so is sitting over steaming 
water. An anodyne will often be necessary in addition to con- 
trol the vesical tenesmus, pain and irritability. The remedy par Opiates 
excellence is opium and its alkaloids. It should be given by 
mouth or rectum. If given by mouth, the addition of fol. uvae 
ursi, or the time honored linseed decoction with salol will be 
serviceable : 



Dose and ad- 
ministration 



Decoct, sem. lini. 


or 


(infus. 


fol. 




uvaa ursi), 








10.0-150.0 


Salol, 








4.0 


Tinct. opii spl., 








gtts. XX. 


Syr. spl., 








30.0 



Sig. A tablespoonful every two hours. 



244 



For suppositories the extract of opium should be combined 
with the extract of belladonna: 



Balsams 
Santal oil 
Pichi Pichi 
Gonosan 
Uva ursi 
Buchu 
Herniaria 



Internal anti- 
septics 



Salol 



Boric acid 



9 



0.18 



0.06 
6.0 



Camphoric acid 
Benzoic acid 



Extract of opium, 

or (Morphine sulphate, 0.08) 
Extract of belladonna, 
Olei cacao, 
Ft. suppositories No. vi. 
Sig. One suppository twice to three times a 

day. 

The balsams, oleum santali, fluid extract of pichi pichi, 
Gonosan, a combination of kava kava and purified sandalwood 
oil, all have a sedative effect in acute cystitis. The folia uvae 
ursi, the folia buchu and the herba herniarige are also still in 
use. They are taken as infusions, either singly or in mixture 
of equal parts of these herbs, about a heaping tablespoonful to 
a large cup of boiling water. Gonosan is free from the disa- 
greeable effects of the sandalwood oil and to avoid the unpleas- 
ant eructations should be taken on a full stomach, and very little 
of fluids consumed during or soon after the meal. The dosage is 
two to three capsules, three times daily. It is especially efficient 
in gonorrheal cystitis. 

Sometimes it will be necessary to give internal antiseptics in 
order to attack the root of the evil. The most commonly em- 
ployed remedies of this class are salol, camphoric acid, boric 
acid, benzoic acid and last, but not least, urotropin. Salol is 
given in doses of 0.3 to 0.5 gm., three times daily; being a 
phenol derivative, it should not be prescribed where kidney 
lesions exist. 

Combining useful antiseptic and astringent qualities is the 
following formula: 

Salol, 

Extract of uva ursi sice, aa 5.0 

M. ft. Pill, No. XXX. 

Sig. Two to three pills three times daily. 

Boric acid, to be effective, has to be taken in doses of 0.5 
to 1.0 gm., several times a day; this occasionally, it must be re- 
membered, may cause toxic symptoms such as exanthema, albu- 
minuria and extreme weakness. 

The dosage of camphoric acid is 1.0 gm., three times a 
day, of benzoic acid 0.3 to 0.5 gm., three times a day. Both have 



CYSTITIS 245 

a marked deodorizing effect on ammoniacal urine, but distress 
the stomach if given for a long time. 

In urotropin we possess the strongest urinary antispetic of Urotropin 
more recent date. However, it does not seem to have any effect 
on the gonococcus or the bacillus tuberculosis. It requires an 
acid urine in the renal pelvis in order to develop its active 
principle, formaldehyde, but the latter after being once liber- 
ated, acts alike in acid or alkaline urine. In the cystitis of 
typhoid fever it is, so to say, a specific. It is given in doses of Dose and ad- 
0.3 to 0.5 gm. twice to three times daily and should always be mmistratl0n 
dissolved in a few ounces of water in order to avoid distressing 
stomach symptoms. It may be used for weeks and months with- 
out any ill effects. Occasionally albuminuria and hematuria may 
be observed, which rapidly subside when the drug is discon- 
tinued. It rarely causes dysuria, excepting occasionally in an 
ulcerated bladder. In these cases helmitol, another formalde- Helmitol 
hyde preparation, has been used, but with no better results. 

While in many cases the symptoms of acute cystitis dis- Local applica- 
appear under this treatment, it sometimes becomes necessary tions to the 
to make local applications to the bladder besides. The key to 
this treatment is given by the intolerance to tension of the in- 
flamed bladder wall. Therefore, large or even moderately large 
injections are objectionable and only soft instruments of small- 
est calibre should be introduced. 

The best method to employ is instillation, performed by Treatment by- 
applying locally drop by drop the active medicinal solutions to ms 1 a 10n 
the inner surface of the bladder wall. The strength of these 
solutions used, the small quantity of fluid instilled, and the slow- 
ness with which one by one they enter the viscus, are the import- 
ant points to be attended to. Instillations should not be hur- 
riedly given, or they then become injections; the solution, 
although by no means always a caustic one, is far stronger than 
could be used in the form of an injection, and this constitutes 
the chief virtue of instillations. 

The instruments required are a small, graduated syringe and 
the instillator, which is a perforated, gum elastic, olive tipped 
bougie. In Guyon's syringe the contents is one dram. In the 
first place, the bladder, as in all instrumentation of the urethra, 
should be empty. The quantity used should never exceed one 
dram. The strength of the solution that may be used is as great 
as its quantity must be small. While the bladder could not be 
irrigated with a nitrate of silver solution stronger than 1 in 
500, instillations of from one to five per cent, may be used with 
perfect toleration. 



246 



Solutions of the strength of 1 in 20,000 of bichloride of 
mercury may be used for injections, but for instillations of solu- 
tions the strength of 1 in 5000 and 3000 may be used and some 
patients even support 1 in 1000. But as a rule the first instilla- 
tions should be still milder, the concentration of the nitrate of sil- 
ver solution not to exceed 1 in 1000 and the bichloride of mercury 
1 in 10,000. "When increasing the strength the quantity should 
be decreased, as for instance of % to 1 per cent, nitrate of sil- 
ver solutions or of 1-2000 to 1-1000 bichloride solutions not more 
than 15 to 30 drops should be used. 

The substances that will be found most satisfactory may be 
divided into (1) anesthetics, and (2) antiseptics. 

Anesthetics 1. Anesthetics are very valuable as treatment in themselves 

and as a preliminary to instillations of more or less painful 
solutions. In mild cystitis, where there is no excessive tenes- 
mus to tension, antipyrin in ten times its weight of water ren- 
ders the mucous surface of the bladder less sensitive to the sub- 
sequent application of nitrate of silver. In very acute cystitis 
guaiacol is superior to antipyrin and cocaine, especially in the 
formula of Pirot, viz., iodoform, 1 part, guaiacol, 5 parts; steril- 
ized oleum benne, 100 parts ; of which solution one dram may be 
injected three times daily without any inconvenience. Great care 
has to be exercised in applying cocaine to the bladder cavum, on 
account of its ready absorption from raw surfaces. A good 
rule is never to exceed the injection of one and one-half to two 
grains of the drug. 

Antiseptics 2. Antiseptic Instillations. Perchloride of mercury in solu- 

tion of 1 in 5000 or 1 in 3000 will be found of great service, 
especially in the constant and prolonged agony of tuberculous 
cystitis. Its effect is still more pronounced if used alternately 
in two days' intervals with the iodoform guaiacol suspension 
given in the preceding formula. Another specific in tuberculous 
cystitis is "Gomenol. " Its analgesic action is equal to that of 
guaiacol while its antiseptic properties are more pronounced. It 
is used in the form of instillations of 10 per cent, and 20 per 
cent, gomenoloil, one dram of the oil being instilled into the 
empty bladder night and morning. 

Nitrate of silver is perhaps the most valuable local agent in 
the treatment of cystitis. The more acute, the more painful 
the cystitis, the more frequent the desire to micturate, the more 
clear is the indication for instillations with nitrate of silver, 
hence its effect is little short of astounding in acute gonorrheal 
cystitis. In recent years I have quite extensively used argyrol 
in acute and sub-acute cystitis, and it has given me much satis- 
faction. Being inferior to the nitrate of silver as a germicide it 



CYSTITIS 247 

lacks the irritating quality of the latter, a point to be considered 
in the presence of so much pain and suffering in acute inflam- 
mation. For instillations 4 cc. of a 5 per cent, to 20 per cent, 
solution of argyrol may be used. 

In the more chronic state irrigations of the viscus become 
necessary when the viscid pus clinging to the bladder wall, or 
mineral deposits in a diverticle, call for a thorough cleansing 
preceding other topical applications. But even then one should 
never inject more than two ounces at a time, because the blad- 
der muscle reacts differently towards slow or rapid tension, a 
fact of which one may convince himself by rapidly filling a 
normal bladder with ten ounces of fluid. There will be tenes- 
mus for quite a while afterward, while the same bladder does 
not take notice of such a quantity if accumulated in the natural 
way and time. The result of such rapid filling of a diseased 
bladder is seen in renewed congestion and secretion and many 
a protracted cystitis is due to this procedure. Moreover, the 
cleaning of the bladder wall is much more thoroughly accom- 
plished by small and repeated flushings than a few large ones. 
For all these reasons a sterile piston syringe is preferable to the 
time-honored irrigation can. Chinosol and pyoktanin in a solu- 
tion of 1 in 4000 have a marked deodorizing effect on very 
offensively ammoniacal urine. One dram of a 5 per cent, iodo- 
form suspension most effectively checks ammoniacal decomposi- 
tion of the urine but the strong odor of the remedy prevents 
its general adoption outside of a hospital. Salicylic acid in solu- 
tion of 1 in 3000 dissolves phosphatic debris and renders an 
alkaline urine neutral or slightly acid. A saturated solution of 
boric acid, or a solution of 1 in 3000 of acetate of lead has a 
soothing effect in simple congestion of the mucosa associated with 
a mucous secretion, but it is of no antiseptic value. 

If with all these procedures no marked improvement becomes 
noticeable within a reasonable time, one has to resort to cysto- 
scopy to determine the real condition back of a sympto- 
matic cystitis, which is not amenable to a radical cure unless 
the original cause is removed. 

Stones will have to be crushed or removed by lithotomy. Cystoscopy 
Ulcerations must be curetted and cauterized through the opera- 
tion cystoscope, or excised through a suprapubic or a vaginal 
opening, as the case may require, and a rebellious cystitis 
dolorosa, where the whole bladder wall represents a large slough- 
ing ulcer, requires broad incision and drainage, like any other 
abscess. Topical applications and internal medication will fail 
when strictures, prostatic obstructions or a diverticle cause the 



248 



ACUTE URETHRITIS 



formation of a pool of stagnating residual urine in the bladder 
which forms an excellent culture medium for microbes. 

It is, of course, also impossible to restore normal conditions 
of the bladder wall if a continuous or interrupted stream of 
pus from adjacent organs or from the upper or lower urinary 
passages floods the vesical cavity. Neither will local treatment 
in secondary tuberculous cystitis be efficient, unless we support 
the reconstructive power of the tissues by a general hygienic 
treatment of the system, or by the removal of the primary seat 
of the trouble. 



Non-infectious 
urethritis 



Infectious ure- 
thritis 



VII. ACUTE URETHRITIS.* 

(By Dr. F. Kreissl, Chicago.) 

The treatment of acute urethritis depends upon its etiology. 

The discharges of non-infectious urethritis, as observed 
under various and different etiological conditions, show a marked 
tendency to a rapid cure, if the cause is recognized and removed. 
A urethral secretion following a traumatism like the use of in- 
struments, foreign bodies, a new-growth in the canal, masturba- 
tion or excessive coitus, will spontaneously cease when the cause 
of the trouble ceases to exist. This will also occur in discharges 
due to chemical irritations such as strong injections with bichlo- 
ride or silver solutions, frequently used as a prophylactic after 
cohabitation. Urethral secretions appearing as a part of the 
symptoms of general conditions such as gout, constipation, 
phosphaturia and oxaluria, will yield to the proper constitutional 
treatment of these ailments. 

The four best known types of infectious urethritis are, in 
the succession of their frequency : 

1. Gonorrheal urethritis. 

2. Infectious urethritis of non-gonorrheal origin. 

3. Urethritis tuberculosa. 

4. Syphilitic urethritis. 



1. GONORRHEAL URETHRITIS. 

The efforts made for years to prevent the results of an inocu- 
lation with the gonorrheal virus, in short, to find an effectual 
prophylactic, seem to have been rewarded. In a two per cent, 
nitrate of silver solution, or in a four per cent, protargol solu- 
tion, we now possess a reliable preventive. To this end, a few 



Chronic urethritis is amenable to successful treatment only at the 
hands of the skilled surgeon-specialist and will hence not be discussed 
in this volume. 



GONORRHEAL URETHRITIS 249 

drops of either solution are applied with a syringe or a glass 

dropper in the fossa navicularis and there retained for a few 

minutes, shortly after a suspicious cohabitation. 

This should be tried in every case of urethritis which is not At, ortive treat- 
ment 
older than three days. While, of course, the best results may be 

expected on the first day of the manifestation of the disease, 
there are sufficient proofs that the gonococcus does not always 
penetrate so rapidly into the tissues as to escape the influence of 
the germicide even after a few days; and as long as no harm 
can be done by this treatment, if judiciously applied, it is worth 
while to attempt an abortive cure within the above time limit. 
After irrigating the anterior urethra with a hot boric acid solu- 
tion, I constrict the urethra at the peno-scrotal junction with a 
rubber band, inject one drachm of a four per cent, protargol 
solution and have it retained for five to ten minutes. For the 
irrigation with the boric acid solution a piston syringe is used 
and a sterile elastic catheter. No pressure to distend the urethra 
should be applied and the fluid should commence flowing through 
the catheter before it enters the urethra; this prevents the dis- 
semination of infectious material. 

During the following eight days I irrigate the anterior Treatment dur- 
urethra in the same way with a pint of a 1 :5000 hot nitrate of d ^ s rs eig 
silver solution, once a day. The discharge, if there is any, is 
examined microscopically every day. If no gonococcus is pres- 
ent in the last five specimens, the treatment is discontinued; 
otherwise, the systematic treatment for gonorrheal urethritis is 
commenced. 

The use of alcohol is absolutely prohibited except in patients Systemic treat- 
in whom, from long continued habituation, grave nervous dis- 
turbances would follow its sudden withdrawal. In these cases Avoidance of 
some claret diluted with water may be allowed. 

Sexual excitement and physical exertion must be rigorously Sexual life 
avoided. 

The diet should be non-stimulating. Meats in excess, highly Diet 
seasoned foods, strong tea or coffee are to be avoided in the acute 
stage. 

A well fitting suspensory bag will relieve the sensation of Suspensory 
dragging on the spermatic cord when the patient has to be much 
on his feet. A piece of antiseptic gauze — not cotton — to catch 
the discharge should be placed around "the glans penis in such 
a way as not to constrict the urethra. Most convenient for this 
purpose are the little bags called gonorrhea bags. For women, 
a gauze sponge saturated with an antiseptic should be placed be- 
tween the labia? and renewed after each micturition. 



250 



GONORRHEAL URETHRITIS 



Local 
ment 



treat- The local treatment of the infected area should be com- 

menced at once, irrespective of the stage of the disease. The 
best results, the most rapid recoveries and hardly any compli- 
cations are observed under these conditions. 

In order to deal successfully with acute gonorrheal urethritis 
the following points should be remembered: 

1. The acute symptoms are due to the irritating qualities of 
the toxins. 

2. The tissues if slightly assisted are usually capable of 
taking care of the gonococcus, consequently the toxins will have 
to be frequently removed and the gonococcus as far as it can be 
reached destroyed by a remedy which does not increase the in- 
flammatory conditions already present. 

Therefore, injections and not irrigations under pressure have 
to be employed and even Janet, the sponsor of the irrigation 
method for acute gonorrheal urethritis, has come to my point of 
view on this subject as I expressed it many years ago. The 
syringe should have a capacity of three drachms, should have 
a blunt tip and may be made of glass, rubber or metal so that 
it can be thoroughly cleansed and sterilized. The quantity to 
be injected at a time depends on the capacity of the anterior 
urethra; however, enough fluid should be used to slightly bal- 
loonize the canal without any perceptible discomfort to the 
patient. It should also be borne in mind that the capacity of 
the urethra varies with the degree of inflammation. 

The remedy which has given me the most satisfactory re- 
sults for many years, and which now seems to be generally rec- 
ognized as the most valuable, is protargol. If judiciously used 
it promptly destroys the gonococci, where they can be reached 
by this specific; it shortly allays inflammation, and surely pre- 
vents complications. 

The strength of the solution, the frequency of the injection 
and the length of time it is to be retained depend on the stage 
of the disease. Generally speaking, I would say that in the 
acute stage with much inflammation the solution must be very 
dilute ; it should be injected at short intervals and retained but 
a minute. With the acute symptoms subsiding the strength may 
be increased, the frequency of the injections reduced and the 
solution retained longer. 

As a routine treatment for this class of cases I would rec- 
ommend the following procedure : 
Technique The patient should urinate before each injection so as to 

mechanically remove the secretion from the urethral wall. He 
should then inject a one-eighth per cent, solution of protargol 
and retain it for one minute, repeating the treatment every two 



Protargol in- 
jections 



Strength of the 
solution 



GONORRHEAL URETHRITIS 251 

hours during the day and twice during the night. The latter importance of 

point is of the utmost importance for a speedy and safe cure, n ig" n t injec- 
tions 
and many complications and chronic cases are due to the neg- 
lect of this rule, which I have tried to impress upon the prac- 
titioner for many years. 

After three days a 14 P er cent, solution should be injected 
every three hours during the day and once during the night. 
At the end of the first week the strength of the solution may be Treatment dur- 

increased to y 2 per cent, to be injected every four hours and re- "J? second and 

tnird week 
tained five minutes and the night injections discontinued. At 

the beginning of the third week the same solution is injected 
three times a day and retained ten minutes at a time. At the be- 
ginning of the fourth week, when the secretion will be found to Fourth week 
contain mostly epithelial cells, none, or but a few, leucocytes and 
no gonococci, an astringent and mild antiseptic will be substi- 
tuted for the morning and noon injection with protargol, but the 
latter is still to be used before retiring. In the following two 
weeks only the astringents may be injected, if repeated examina- 
tions have shown the permanent absence of gonococci. 

The most commonly employed and the most serviceable astrin- Astringents 
gents are : 



Zinc sulphocarbolate, 


0.60 


Resorcin, 


1.80 


Aqua distill., 


140.00 


Fluid extract Hydrastis, 


40.00 


Sig. Inject mornings and noon. 




Zinc sulph., 


1.0 


Plumb, acet., 


2.0 


Aqua distill., 


200.0 


Sig. Inject mornings and noon. 





This is the old Ricord's formula. 

Cupr. sulph., 0.20 

Alum crud., 1.00 

Aqua distill., 200.00 
Sig. Inject mornings and noon. 

The astringents should only be retained for a minute at a 
time. 

Fresh solutions of protargol, not older than three to four 



252 



GONORRHEAL URETHRITIS 



Preparation of 
solutions 



Female gon- 
orrhea 



Bougies 



Vaginal 
douches 



Toilet of ex- 
ternal parts 



Complications 
in women 



Acute posterior 
urethritis 



Gonosan 



days, should be used and they should, therefore, not be made 
from stock solutions and must be kept in stained glass bottles. 
They should be prepared slowly by spreading the powder on 
the surface of cold water and not by mixing, stirring, heating 
or by the addition of solvents. These small details seem to be 
overlooked quite frequently but are important to obtain good 
results. 

The female urethra is not suitable for injections nor is it 
possible to retain fluids therein for any length of time. Instead 
of these I have always successfully employed urethral bougies, 
one and one-half inches long, made of protargol and gelatin. 
They are inserted in the urethra once and, later on, twice a day 
and there retained for ten to fifteen minutes by a pledget of 
gauze or cotton slightly pressed against the urethral orifice. By 
squeezing the bougie for an eighth of an inch upward from the 
orifice oftentimes no artificial retention at all, in the recum- 
bent position, is necessary. After the gonococcus has disap- 
peared from the discharge, astringent, medicated bougies are in- 
serted on alternating days with protargol bougies for about two 
weeks. and, finally, the astringent alone for another week. Pre- 
cautionary hot vaginal douches with a quart of a 1 in 3000 pro- 
targol solution, or 1 in 10,000 nitrate of silver, twice and later 
once a day, are used. The vestibulum, the area around the 
vulvo-vaginal glands, the urethra and the clitoris should also 
be cared for in the same way. Occasionally, but rarely, it will 
be necessary to employ protargol solutions as strong as 1 per 
cent. ; they may not be used more than once a day and, if found 
inadequate, a 1 in 2000 nitrate of silver solution, injected twice 
a day, may be substituted with satisfactory results. Where this 
fails after it has been tried for a reasonable time, closer inves- 
tigation will reveal some complication, the most common being 
infection of a paraurethral duct; a periurethral or a follicular 
abscess; invasion of the Cowper glands; or the disease has 
crossed the external sphincter and invaded the posterior urethra 
with or without producing acute inflammatory symptoms. 

Acute posterior urethritis, which is characterized by symp- 
toms identical with those of acute cystitis, requires rest in bed 
for a few days, a strict milk diet, care for the bowels, in short, 
the same management as acute cystitis. Injections in the ante- 
rior urethra should be discontinued until the acute symptoms 
have subsided and the medication indicated for acute cystitis 
instituted. Gonosan, which I prescribe in these cases, has not 
the least specific effect on the gonococcus, as is claimed for it, 
but it renders the urine bland and helps to allay the inflamma- 
tory symptoms. With the improvement of these symptoms the 



GONORRHEAL URETHRITIS 253 

injections may be resumed and local treatment of the deep 
urethra and the vesical neck added. Daily, deep injections with 
one drachm of a 1 per cent, to 2 per cent, protargol solu- Deep injections 
tion will answer the purpose. They are given like bladder in- W1 
stillations (see Section on Cystitis), with the difference that the 
tip of the catheter or of the instillation bougie is placed in the 
vesical neck and the solution is deposited, drop by drop, over 
the whole inflamed area while the catheter is being slowly with- 
drawn to the external sphincter. 

Prostatitis. 

This complication of acute gonorrheal urethritis requires 
besides the treatment for acute posterior urethritis, appli- 
cations of cold to the posterior aspect of the prostate in order to 
prevent suppuration. This is best accomplished through the 
rectophore applied for fifteen to thirty minutes, several times Rectophore 
daily. The temperature of the water circulating through the 
apparatus should not be so low as to produce discomfort. Ice 
bags applied to the perineum add to the comfort of the patient. Ice bags 

Eetention of urine, as it occurs in some of these cases, may Retention of 
be relieved by catheterizing under the necessary and well-known 
antiseptic precautions. Only soft rubber catheters are permis- Catheterization 
sible for this purpose. If, in spite of antiphlogistic treatment, 
pus forms and a prostatic abscess can be palpated through the Prostatic ab- 
rectum, one should not be too hasty with an operation as the 
abscess frequently ruptures spontaneously into the deep urethra, 
an event that is announced by the appearance of much pus mix- 
ed with the urine and a remission of all distressing symptoms. 
If the abscess does not rupture spontaneously within a few days 
after it becomes palpable, it should be evacuated by a perineal 
opening to prevent serious complications, for, if not surgically Surgical relief 
relieved, the pus might break through the capsule and burrow 
its way beyond our control. 

Epididymitis. 

The indications for the treatment of this disorder are : 

1. To relieve the pain and inflammation, and 

2. To promote the absorption of the inflammatory products. 

The first indication is best accomplished by rest in bed, a Rest 

suitable support for the testicle and the application of heat 

in the shape of hot fomentations or a hot poultice. If taken in Heat 

hand before the acute symptoms have reached a climax the 

following procedure has always given me satisfaction: Apply 

a solution of equal parts of guaiacol and glvcerin with a brush Guaiacol and 

glycerin appli- 
or a gauze sponge all over the scrotum of the afflicted side ; this cations 

causes considerable smarting for several minutes. The whole 



254 



GONORRHEAL URETHRITIS 



Suspensory- 



Internal treat- 
ment 



Moist heat 



Scarification of 
the tunica 
vaginalis 

Abscess of 
epididymis 



Latent tuber- 
culosis 



scrotum is wrapped in a square of absorbent cotton, 12x12 
inches, and one inch thick. This is covered with a piece of oil- 
silk or rubber protective tissue of the same size and the whole 
held in place by a large sized suspensory bag. The bag for this 
purpose must be extra large to accommodate the voluminous 
mass to be placed therein and should have a strong elastic abdom- 
inal band, the latter to be adjusted high enough to suspend the 
testicle as high as possible. The guaiacol acts as an antiphlo- 
gistic and an anodyne, the cotton, covered with oilsilk, as a dry 
poultice, and the suspensory, if properly adjusted, takes away 
all the dragging of the testicle on the tender and inflamed cord. 
The effect is a momentous one, patients whose features were dis- 
torted with pain, are able to walk briskly immediately after the 
testicle is immobilized in the manner described. One applica- 
tion of the guaiacol is sufficient but the cotton, being worn down, 
has to be renewed at least once in twenty-four hours. 

Three grains of salicylic acid with lemonade, taken twice 
daily, seems to assist in the acute stage. Within five to eight 
days the swelling of the epididymis is usually reduced by one- 
half and the greater part of the inflammatory effusion in the 
albugineal sac has become absorbed. 

Moist heat furthers the removal of the infiltration in the epi- 
didymis at this stage. Eight thicknesses of a piece of moist 
gauze, 12x12 inches, are wrapped around the whole scrotum, 
this is covered with oilsilk of the same size, over this is placed a 
layer of cotton, 12x12 inches and one-half inch thick, and the 
whole is supported in the suspensory bag, to be renewed morn- 
ings and nights. In a few cases the very profuse effusion in the 
albugineal sac causes so much tension that absorption becomes 
impossible. In this event Vidal's multiple scarification of the 
tunica vaginalis will be necessary to open an avenue for the 
escape of some of the fluid. In rare instances abscess formation 
in the epididymis occurs, in which event broad incision of the 
albugineal sac and evacuation of the pus will bring speedy re- 
lief. This pus ought to be carefully examined, as usually a 
latent tuberculosis is back of these suppurations. The same 
should be remembered in the ever recurring swellings of the 
epididymis without a palpable cause. 

All local treatments have to be discontinued in the acute 
stage of epididymitis and no balsams of any kind given in- 
ternally. Many a case of a persistent acute inflammation will 
readily disappear under proper treatment when this latter point 
is observed. 



INFECTIOUS URETHRITIS 255 



2. INFECTION URETHRITIS OF NON-GONORRHEAL ORIGIN. 

Owing to the fact that very little is known about the nature Causes 
and origin of this peculiar form of urethritis, it is not surprising 
that we do not as yet possess any definite means to successfully 
deal with the trouble. Streptococcus, staphylococcus, pneumo- 
coccus, pseudo-diphtheria bacillus and coli-bacillus which are 
found in the discharge of these cases also exist in the normal 
urethra without producing any symptoms. From observations 
extending over a number of years it seems to me that these micro- 
organisms occasionally become virulent on a mucosa which by 
some provocation has lost its natural powers of resistance and 
has thus become transformed into a favorable culture medium; Predisposing 
in fact, upon inquirjr we can often trace the trouble to a pre- factors 
ceding sexual excess, prolonged and violent exercise, forcible 
urethral instrumentation, etc. I have seen such discharges ap- 
pear after sexual excesses carried on with the protection 
of condoms, and after instrumentation under all possible anti- 
septic precautions, so that a transmission of the infection was 
at least in these cases out of question. In others the infection 
occurred simultaneously with the inoculation with the gono- 
coccus, and in still others a chronic gonorrhea rendered the ure- 
thra more susceptible to the subsequent mixed infection. 

Regarding treament very little of value can be said. The 
few cases of coli infection which I have seen yielded promptly 
to internal medication with large doses of urotropin or other xj ro tropin 
formaldehyde preparations. In a few staphylococcus infections 
mercurol, in one-half to two per cent, solutions, proved very M , 

effective; also two per cent, ichthyol solutions, provided the 
patient could tolerate the smarting sensation caused by the med- 
icine. 

In one case in which the urethroscope showed several islands 
of pseudo-membrane, and the culture nothing but pseudo- 
diphtheria bacillus, I used antitoxin hvpodermically on two sue- ^. , A , 

' ,. , t t-t Diphthena-an- 

cessive days, and the discharge disappeared. I have seen the titoxin 

case since then repeatedly. This is now over two years ago, 
and everything is apparently normal. Perhaps a urethral in- 
jection with the antitoxin might have had the same effect. En- 
couraged by this result I tried this treatment in other cases in 
which the diphtheria bacillus was found in company with 
staphylococcus and pneumococcus but without success. In a 
few cases I used electrolysis in apparently diseased pockets and Electrolysis 
follicles with good results. 



256 



URETHRITIS TUBERCULOSA 



Intractable 
character of 
the trouble 



Radio-active 
fluids 



Very few of these cases seem to improve under any method 
of treatment, but they get worse as soon as treatment is discon- 
tinued, and most of them even while under the treatment. A 
few recover without any treatment, some of them completely, 
some to that extent that the discharge ceases, but shreds are 
constantly present in the urine. Most of them seem to remain 
well for days, weeks, even months at a time, when with or 
without evident cause the secretion reappears. Several times I 
have seen the trouble permanently disappear after a reinfection 
with gonorrhea. One of my patients, who carried this infection 
for over two years, lost it permanently after a severe typhoid 
fever. 

Light having a deleterious effect on pneumococcus and bacil- 
lus diphtheriticus, I utilized injections with radio-active fluids, 
but with the same varying results. A specific has still to be 
discovered. 



Hygienic and 

symptomatic 

treatment 



6. URETHRITIS TUBERCULOSA. 

As a rule, this is the local manifestation of the constitutional 
trouble or the partial symptom of a more or less generalized 
tuberculosis of the urogenital tract, and requires a hygienic 
and symptomatic treatment. Instrumentation is to be avoided. 
The same topical treatment as in cystitis tuberculosa may afford 
some relief, but a cure depends on the extent of the urinary 
lesion and the possibility of dealing successfully with the lat- 
ter, and in this respect the prospect is not very encouraging, 
as the disease is usually far advanced before urethral manifesta- 
tions are observed. 



Injections of 
bichloride so- 
lutions 



Bougies 



4. SYPHILITIC URETHRITIS. 

If caused by the primary lesion of syphilis — the hard 
chancre — the proper local and constitutional treatment (see 
Section on Syphilis) is sufficient. The ulcus being situated near 
the orifice can easily be reached by local medication. This con- 
sists in injections with a drachm of a 1 in 5000 bichloride solu- 
tion, twice a day, followed by the insertion of a urethral bougie, 
one inch long and one-eighth of an inch thick, consisting of: 



h 



Olei cacao, 

Iodol, 

Ft. Urethral bougie. 

Sig. One twice a day. 



0.30 
0.06 



SYPHILITIC URETHRITIS 



257 



If the healing is retarded, or bleeding due to flabby granu- 
lations is observed, the ulcer has to be exposed in a short ure- 
throscope and cauterized with a concentrated nitrate of silver, 
or sulphate of copper solution — from 10 per cent, to 50 per cent. 
Secretions, due to secondary syphilitic lesions in the urethra, 
readily yield to the constituional treatment supported by a few 
irrigations of the anterior urethra with a 1 in 1000 nitrate of 
silver solution. 



Cauterization 



Nitrate of sil- 
ver irrigations 



CHAPTER VI. 



DISEASES OF THE MOUTH AND UPPER AIR 
PASSAGES 

INTRODUCTION. 

Nearly all the diseases of this region of the body call for 
topical and surgical treatment. A few of the more acute varie- 
ties, especially those that are complications or part phenomena 
of general constitutional or infectious diseases, however, belong 
to the province of the internist. The more chronic disorders that 
are accompanied by advanced anatomic changes (hyper- 
trophies and atrophies, deformities, abscess, ulcer formation, 
etc.) should be treated by special surgeons alone. Whereas the 
latter should by all means be competent general practitioners, 
it is nowadays not necessary nor, for that matter, possible, for 
the general practitioner to be a competent specialist. It is, in 
fact, almost more important that the latter should recognize 
his limitations in this direction, than that he should attempt 
without adequate training to encroach upon the domain of the 
skilled, experienced specialist. It is due precisely to failure on 
the part of the general practitioner to recognize these limitations 
that there is so much promiscuous, uncalled-for, and generally 
harmful spraying and applying, cutting and cauterizing about 
the nose and throat. 

The diseases of the mouth and upper air passages that the 
internist is frequently called upon to treat, either because their 
onset is very acute or because they accompany various general 
disorders, are the different forms of stomatitis, acute rhinitis, 
including hay fever and pseudo hay fever, pharyngitis, acute ton- 
sillitis and acute laryngitis. The treatment of these disorders 
alone, therefore, will be discussed in this chapter. 

I. DISEASES OF THE BUCCAL CAVITY. 
STOMATITIS. 

Stomatitis complicates a variety of infectious diseases, gastro- 
intestinal and hepatic disorders, cachexias and anemias, certain Causes 
metabolic disorders as diabetes, the uric acid diathesis and 
acetonemia, the hemorrhagic diathesis. In children during the 
period of dentition, and especially in bottle-fed infants and 
children with rickets, mouth disorders are common. Finally, in 
all unconscious states the mouth is apt to become diseased; the 
stomatitis, in the latter instance, being due in great part to de- 



260 



STOMATITIS 



Prophylaxis 
in acute infec- 
tious diseases 



Mouth washes 



Glycerin 



Prophylaxis in 

cachectic 

conditions 



ficient salivary excretion and the inhibition of masticating and 
swallowing movements, causing the mouth to become dry and 
preparing a particularly favorable nidus for the development of 
bacteria and fungi about the gums, the mucous lining of the 
mouth and the tongue. 

In the acute infectious disorders it is particularly import- 
ant to prevent the development of stomatitis, so that tjhe patients 
during convalescence may not be hindered from eating on ac- 
count of soreness of the buccal cavity. The prophylactic meas- 
ures that must be employed in infectious and in comatose states 
are the following: In order to induce swallowing, to promote 
the flow of saliva and to prevent cracking of the tongue and 
lips, the mouth should be washed out every two or three hours 
with a linen rag dipped either in a saturated solution of boric 
acid, or a three per cent, bicarbonate of soda solution, or a two 
per cent, solution of chlorate of potash. The latter remedy 
should not be used if the kidneys are affected. In patients who 
are altogether unconscious the tongue should be painted with 
glycerin, or boric acid in glycerin in the proportion of one part 
of boric acid to four parts of glycerin, and so much should be ap- 
plied that a portion of the glycerin trickles down into the 
pharynx. Ice pills should be inserted into the mouth or tea- 
spoonful doses of lemonade poured in at frequent intervals. In 
order to force swallowing movements, pressure may be exerted 
upon the base of the tongue. On the lips glycerin should not 
be used because it is too hygroscopic. Here vaseline or lanolin 
are the proper applications. If all these measures are carefully 
carried out a sore mouth will rarely develop, even in so pro- 
tracted a disease as typhoid fever. 

In chronic cachectic conditions, in sufferers from the hem- 
orrhagic diathesis, in diabetes, the following mouth wash is 
very useful: 



? 



Biborate of soda, 
Menthol water, 
Distilled water, 
M. Sig. Mouthwash. 



30 gm. 
150 cc. 
950 cc. 
- ( Ortner. ) 



Fetor 



Of this mouth wash a teaspoonful in half a glass of water 
should be used as a cleansing solution after each meal. 

A useful prescription for the excessive fetor in diabetes has 
been given on page 140. The following astringent wash is also 



STOMATITIS 


261 


very useful, particularly if there is a 


tendency to bleeding from 


the gums: 


Bleeding gums 


r> 




Thymol, 


35 gm. 


Benzoic acid, 


3 gm. 


Tincture of eucalyptus, 


15 cc. 


Absolute alcohol, 


100 cc. 


Peppermint oil, 


20 drops 


M. Sig. Mouthwash. 


—(Miller.) 



Of this solution a teaspoonful in half a glass of water should 
be used as a wash or gargle. 

In all forms of stomatitis, too hot, too cold, too hard or 
rough articles of food, spices, strong alcoholic beverages, and 
also tobacco should be carefully avoided. 

If the mouth disorder is once established the treatment differs 

somewhat according to the character of the stomatitis. For ^. . .. 

3 , Five varieties 

practical purposes it is convenient to distinguish five varieties, of stomatitis 
First, simple catarrhal or erythematous stomatitis; second, 
aphthous (follicular or ulcerative) stomatitis; third, thrush 
(stomatitis due to oidium albicans) ; fourth, gangrenous stoma- 
titis (noma, cancrum oris) ; fifth, mercurial stomatitis and 
ptyalism. 

In the simple catarrhal form the measures described under 
prophylaxis should be employed for the sake of promoting Treatment of 

cleanliness and antisepsis of the mouth. At the same time any f iinp j e catarr ~ 

r J hal form 

underlying constitutional, gastro-mtestmal or hepatic disorder 

should be treated. No special local treatment is required. 

In the ulcerative or aphthous form each ulcer should be 
touched with a stick of silver nitrate, or cauterized with a Treatment of 
galvano-cautery or a Paquelin. The best liquid application in ulcerative and 
the ulcerative form is a mixture of potassium chlorate in gly- 
cerin in the proportion of one to two. Potassium chlorate is a 
particularly useful remedy in the ulcerative form, but should 
be used carefully in the aphthous, for, in the latter, it increases 
the pain. If kidney disease is present it should never be used. 
Potassium is excreted in part through the saliva, so that it 
usually grants a prolonged local effect in the mouth. A one 
per cent, sodium salicylate solution, or a one to one thousand 
permanganate of potash solution, may also be used for wash- 
ing out the mouth and touching up the ulcers. If the mouth is 
very sore and painful a few drops of opium tincture or cocaine 



262 



STOMATITIS 



may be added to the solutions, 
the following: 



A very useful preparation is 



Salicylic acid, 

Cocaine muriate 

Glycerin, 

Water, 

M. 



1.0 

0.1 

10.0 

10.0 



Treatment of 
thrush 



Treatment of 
noma 



Treatment of 

mercurial 

stomatitis 



Potassium 
chlorate 
Peroxide of 
hydrogen 



Thrush is usually preventable if rigid cleanliness of the 
mouth is maintained. In nursing children particular care should 
be exercised to have the nipples clean. Gastro-intestinal 
disorders should be carefully treated and corrected. The best 
local applications are potassium chlorate in a two per cent, solu- 
tion, or potassium permanganate in a one pro mille solu- 
tion. These are best applied on rags that should be rubbed 
against the affected areas in the mouth. Internally, resorcin, 
one to one hundred, in teaspoonful doses, two or three times a 
day, is said to exercise an inhibitory effect upon the develop- 
ment of thrush (Baginsky). 

Gangrenous stomatitis is a very dangerous complication and 
one that always calls for energetic local treatment. The gan- 
grenous areas should be destroyed either by a galvano-cautery 
or a Paquelin cautery, or by the application of nitric acid or 
silver nitrate in stick form. If the line of demarcation does 
not form within a day or two an artificial line of separation 
should be produced by the use of these caustics and the gan- 
grenous areas excised. 

Mercurial stomatitis can generally be prevented by careful 
mouth asepsis carried out as described under prophylaxis. Cer- 
tain individuals, however, seem to have a peculiar susceptibility 
to mercury and become salivated upon the exhibition even of 
very small doses. As soon as the first evidence of stomatitis 
(usually soreness about the gums) becomes manifest, the ad- 
ministration of mercury should at once be stopped. 

Two remedies are particularly useful in the fully developed 
form, namely, potassium chlorate and peroxide of hydrogen. The 
former should be used in a mouth wash in a two or three per 
cent, solution, or a tooth brush may be dipped into powdered 
chlorate of potash and the teeth and gums energetically brushed 
with it. Peroxide of hydrogen should also be given in the 
strength of about two per cent. As the commercial preparations 
contain about 10 per cent., a teaspoonful to one-third of a glass 
of water approximates the proper concentration. 



TONSILLITIS 263 

If mercurial ulcers develop they should be treated with a 
silver nitrate stick, or should be painted with tincture of iodine 
or touched with chromic acid. Free catharsis should be pro- Atropine 
moted, sweating induced, preferably by hot bathing, and the 
patient should be instructed to drink plenty of water. Intern- 
ally, atropine in one-two-hundredth grain doses given three 
times a day often beneficially influences mercurial stomatitis. 



TONSILLITIS. 



Classification 



Abortive treat- 



The mucous lining about the orifices of the tonsillar crypts 
may become involved in any catarrhal state of the mouth or 
upper air passages, or the crypts alone may be attacked (lacunar 
or follicular tonsillitis) or the whole gland, including its ade- 
noid tissues, may be diseased (parenchymatous tonsillitis), 
or the infection ma} r be suppurative in character (tonsillar or 
peritonsillar abscess). The treatment of these different forms 
does not vary materially. In the suppurative variety, of course, 
surgical evacuation of the pus becomes necessary. 

Upon the onset of the first symptoms the bowels should be ment 
thoroughly evacuated, probably best by the use of ten one-tenth 
grain doses of calomel given at ten minute intervals, followed 
by a tablespoonful of magnesium sulphate in water. The diet 
should be non-irritating to the throat, i. e., should contain no 
rough or hard particles nor spices, nor should it be too hot. 

Internally tincture of aconite, in drop doses, should be Aconite 
given at two hour intervals throughout the attack. The most 
useful remedies for internal use, possibly owing to the intimate 
relationship of tonsillitis to certain forms of rheumatism, are 
guaiac and the salicylates. Guaiac is useful both internally Guaiac and 
and locally, so that its administration in lozenge form is espe- a lcy a e 
cially appropriate in this disease. For internal use the tinc- 
ture of guaiac may be given in tablespoonful doses in milk, sev- 
eral times a day. Sodium salicylate is best given as salol in 
five to ten grain (0.3 to 0.6 gm.) doses, or in combination with 
some alkali, for instance, as ten grains (06. gm.) of sodium sali- 
cylate with ten grains (0.6 gm.) of sodium bicarbonate in some 
simple syrup. This quantity should be administered every two 
hours during the first two days, then every four or five hours 
throughout the course of the disease. 

The local treatment consists in the application of cold ex- Local treat- 
ternally either by means of a Priessnitz compress, i. e., a linen ment 
cloth wrung out of cold water and covered with flannel or, bet- 
ter still, by means of a. Leiter coil (see index) through which plications 



264 



TONSILLITIS 



Internal 
cations 



Gargles 



appli- 



ice water is flowing. Leeching or blistering the neck are rarely 
necessary and usually very disagreeable to the patient. Paint- 
ing the neck with iodine occasionally helps, but this form of 
counter-irritation is inferior to the use of the Priessnitz com- 
press. Sometimes cold applied to the neck is very objectionable 
to the patient; heat may then be applied either by means of 
hot cloths frequently renewed and covered with oiled silk or 
by means of linseed-, oatmeal- or bread-poultices. Cold is, how- 
ever, always more effective in modifying the course of the dis- 
ease than heat. 

The tonsils themselves should be treated by means of gargles 
or by direct applications to the affected glands. The different 
gargles should be used as follows: A small quantity is taken 
into the mouth, the head thrown back, the nose closed with the 
fingers and thumb, the mouth opened and a swallowing move- 
ment attempted. The following gargles are useful: A tea- 
spoonful of alum dissolved in half a pint of water, to which is 
added a teaspoonful or two of some flavoring syrup; or a two 
per cent, solution of potassium chlorate ; or again, the following : 



3? 



Salicylic acid,. 

Glycerin, 

Carbolic acid, 

Water, 

M. 



1.0 gm. 

1.0 cc. 

1.0 cc. 

100.0 cc. 



Sodium car- 
bonate 
Ammoniated 
tincture of 
guaiac 

Inhalations 



Sprays 



Evacuation of 
pus by incision 



If there is pain a gargle of equal parts of lukewarm milk 
and water to which are added twenty drops of tincture of opium 
is very soothing. 

If the tonsils are very much swollen, or if they are very 
painful, gargling is difficult and disagreeable. Here direct ap- 
plications to the tonsils are useful. Dry sodium bicarbonate 
may be rubbed directly upon the tonsils with the fingers, or the 
tonsils may be painted or swabbed with ammoniated tincture of 
guaiac. 

Inhalations through a steam inhaler of a one per cent, solu- 
tion of sodium bicarbonate to which are added a few drops of 
tincture of opium; or spraying the tonsils with a solution of 
five grains of menthol in an ounce of alboline, are soothing 
measures. If there is much mucus from complicating pharyn- 
gitis, then ice cold lemonade sucked through a straw frequently 
aids in expelling it. 

If suppuration becomes established then nothing in the na- 
ture of lozenges, inhalations, sprays or local application should 



ACUTE RHINITIS AND PHARYNGITIS 265 

be used. Here evacuation of the pus by incision becomes nec- 
essary. The indications for the surgical treatment of tonsil- 
litis are the following :* 

"First. Never to inflict unnecessary pain by useless scari- indications for 
fication of the surface of the tonsils undergoing general inflam- ^f^of tern-*" 
mation. sillitis 

"Second. Never to make deep incisions unless there is 
almost certainty of advanced suppuration. The instrument for 
making the incision should be a curved, pointed bistoury with 
not more than one inch of cutting edge, and the cut should be 
made from without inwards, so as to avoid the not impossible 
risk of injuring the artery. 

"Third. To recommend removal, on subsidence of the at- 
tack, of all tonsils chronically enlarged and liable to quinsy. 

"Fourth. To remove the tonsils as soon as they become suf- 
ficiently enlarged, in those cases of recurring quinsy in which 
there is not chronic enlargement, but in which the tonsil though 
diseased is too small for excision except on recurrence of the 
acute inflammation. By this means, the present attack is at once 
cut short and the chance of further recurrence is avoided." 

II. DISEASES OF THE NOSE AND THROAT. 
ACUTE RHINITIS AND PHARYNGITIS. 

Catarrh of the nose and pharynx can fitly be discussed to- 
gether because both these regions are commonly affected simulta- 
neously or consecutively, and because the general treatment of 
acute rhinitis and pharyngitis is in all essentials identical. 

Catarrh of the upper air passages is rarely produced by 
direct irritation of the mucous linings of the nose and throat, 
although what may be called chemical forms of catarrh occur. 
The treatment of the latter form, when the catarrhal condi- 
tion is once fairly established, does not materially differ from 
that of other forms that are due to constitutional causes. 

The most common cause of catarrh of the upper air passages Causes 
is exposure to cold. The nose and throat are a locus minoris 
resistenticB, partly on account of their exposed condition and 
partly owing to the fact that they are chronically in a state of 
irritation from the inhalation of dust or tobacco smoke, from 
contact with alcohol, hot foods, spices, or from irritation by ex- 
cessive use of the voice. Moreover, there is frequently present 
in these passages a condition of passive hyperemia due to ab- 
dominal plethora and tympanitis induced by errors of diges- 
tion and liver disorders, gastroptosis and chronic constipation; 
or due to the wearing of tight collars and neck bands. Inasmuch 



*Quoted from Lennox Browne. 



266 



ACUTE RHINITIS AND PHARYNGITIS 



Action of ex- 
posure to cold 



Prophylaxis 



"Hardening." 



as the blood vessels of these parts are, moreover, especially sus- 
ceptible to reflex vaso-motor influences that ma} 7 " originate in 
many different parts of the body, it is not surprising to find 
the nose and throat particularly liable to inflammation as soon 
as the body is exposed to any influence as, for instance, sudden 
temperature changes, that tasks the adjusting powers of the 
vaso-motor system. 

It is a well known fact that, normally, exposure of any part 
of the body to cold produces, first, a tetanic contraction of 
the capillaries of the exposed area; second, a reactive dilatation 
beyond the normal calibre of the blood vessels; third, a restora- 
tion of the vessels to their original calibre. Unless the vaso- 
motor apparatus is functionating in an altogether normal man- 
ner, the primary contraction may not occur at all or it may occur 
promptly, but last too long. In either case the secondary dila- 
tation, which fulfills the purpose of carrying an increased 
amount of blood to the exposed portion and hence maintaining 
its temperature, does not take place and the first stage of in- 
flammation is produced. This effect is frequently exercised in 
the nose and throat and a catarrh produced in this way. Be- 
sides, cold affecting certain remote regions of the body, espe- 
cially the feet, the back of the neck and the region between the 
shoulder blades, by a peculiar reflex mechanism that is not well 
understood, readily deranges the vascular supply of the mu- 
cous lining of the upper air passages and again catarrh is the 
result. Hence, as is well known, a draft about the feet, the 
back of the neck or between the shoulder blades, in susceptible 
subjects, rapidly produces congestion of the nose and the throat, 
in other words, a "cold in the head." 

In order to counteract this tendency to catch cold, the va- 
rious causes that determine it must be attacked. An intelligent 
and efficient prophylaxis can here be instituted by removing, 
primarily, local causes of chronic irritation and, next, by "hard- 
ening" the organism with an unstable vaso-motor system against 
abnormal reactions to cold. 

The first condition can be fulfilled by eliminating, as far 
as that is possible, all the factors that have been enumerated 
above and that are known to produce irritation of the nose and 
throat. Here, too, the correction of deformities, the removal 
of hypertrophies, adenoid tissue, etc., must be regarded as a 
useful prophylactic measure. 

The "hardening" process must be carried out carefully and 
with due consideration of individual peculiarities. It should 
properly begin in infancy, and babies from the first weeks of 
life should be accustomed to the use of cold water. In adults 



ACUTE RHINITIS AND PHARYNGITIS 267 

suffering from frequent nasal catarrh it is never safe to begin 
at once with cold sponging or bathing, so that the best plan, 
especially in weak individuals, and in old subjects, is to begin 
with dry rubbing of the skin carried on for two or three min- 
utes every morning. Later alcohol may be employed to rub the 
surfaces of the body, then warm and lukewarm water and still 
later cold water. The best way to accustom weakly individuals 

to cold water is to place them into a warm bath of about the „ , „ , , 

... Cold bathing 

body temperature and while friction of the body is being per- 
formed, to gradually cool off the temperature of the water. It 
will be found that from day to day the temperature can be re- 
duced a few degrees without discomfort to the patient until, 
finally, cold water can be employed from the beginning. Warm 
baths alone never harden. Strong and healthy individuals, in 
whom the reaction to cold is very energetic can, of course, with 
impunity begin at once with the use of cold sponging or cold 
plunges even in the coldest weather. Sea bathing, provided the 
individuals do not stay in the water more than two or three 
minutes, that is, until the first reaction appears, is also useful 
in strong people. 

The matter of clothing is of great importance. Most people ° msr 
dress too warmly. The underwear should consist of wool, silk 
or flannel, never of linen or cotton. Linen absorbs the moisture 
quickly and permits its too rapid evaporation; as soon as it be- 
comes wet, it clings to the body and obliterates the layer of 
warm air between the skin and the first garment that is so 
effective as a non-conductor of heat in preventing loss of heat 
from the body surfaces. Wool is a poor conductor of heat and 
gives off the absorbed water very slowly. The fine hairs it con- 
tains hold the material at some distance from the skin so that 
a layer of air is always present between the skin and the wool. 
Its rough texture, moreover, causes some friction and passive 
hyperemia of the skin, which is grateful to the patients and 
renders them less liable to catch cold when they pass from a 
warm room into the cold air. Silk and flannel do not absorb 
moisture so well as wool, but they are very poor conductors of 
heat and as they do not irritate the skin they do not produce 
quite so much perspiration as wool. Chest protectors and back 
protectors and mufflers should be eschewed. The throat can be 
accustomed to exposure to cold as well as the face. The most 
dangerous form of w T rap that can be worn around the throat is, 
of course, fur; for it produces profuse sweating without ab- 
sorbing any of the moisture and hence favors great radiation of 
heat wherever worn. 

The temperature of the living zoom should vary but little The room tem- 
from sixty-five degrees Fahrenheit. The individual who is sus- pera ure 



268 



ACUTE RHINITIS AND PHARYNGITIS 



Abortive treat- 
ment 



Camphor 

Opium 

Atropine 



Foot baths 



Dover's pow- 
der and qui- 
nine and 
aspirin 



Treatment of 
the established 
attack 



Symptomatic 
treatment 



ceptible to catching cold should accustom himself to sleep in a 
cold room, preferably wearing a flannel night-dress and a 
night-cap to protect himself from drafts, and should keep warm 
by using plenty of covers, sleeping between flannel sheets if 
necessary.* 

All the measures enumerated above are particularly useful 
if there is a congenital predisposition to catching cold, or if 
such a predisposition has been acquired by frequent attacks of 
catarrh, or after some infectious disease. In many individuals 
a general neurasthenic or hysteric condition will be discovered 
with abnormal sensibility of the nervous system, or there 
may be chronic anemia that must be corrected (see page 76), 
for in all these cases there is apt to be a perversion of normal 
vaso-motor reactions that must be incriminated with producing 
an abnormal tendency to react by nasal or pharyngeal catarrh to 
exposure to sudden temperature changes. 

TREATMENT OF THE ACUTE ATTACK. 

Upon the appearance of the prodromal symptoms such as 
headache, a feeling of fullness in the frontal region, a little 
chilliness or fever and oozing of a clear fluid from the nose, 
with conjunctival irritation, it is occasionally possible to abort 
the attack by the use of camphor, opium and atropine. It is 
always worth while to attempt this abortive treatment by giving 
three drops each of the tinctures of belladonna and opium in 
half an ounce of camphor water, at three hour intervals, for 
three or four doses. In addition to this internal medication the 
patient should take a hot mustard foot bath and apply a mus- 
tard plaster to the back of the neck. In the evening before re- 
tiring five grains of Dover 's powder with three grains of quinine 
and three grains of aspirin should be administered in capsule, 
together with a glass of hot lemonade containing two table- 
spoonfuls of whisky ; the patient should go to bed and be covered 
with woolen blankets until profuse sweating is produced. 

It is very difficult to abbreviate the attack after the catarrh 
is once fully established. After the first attempt at aborting 
the attack by sweating has been made it is useless to try to in- 
fluence the duration of the disease by further diaphoresis. 
Symptomatic relief may, however, be secured by using a mix- 
ture of one part of menthol to ten parts of chloroform and plac- 
ing a few drops of this solution into the hand and sniffing the 
vapors at frequent intervals. It is also well to thoroughly wash 
out the nose two or three times a day with some alkaline solu- 
tion, such as the following: 



*See also Open Air Treatment of Tuberculosis on pages 313-315. 



CORYZA VASOMOTORIA AND HAY FEVER 269 

Bicarbonate of soda, 0.65 (10 gr.) 

Borate of soda, 0.65 (10 gr.) 

Water, 96.00 (3 oz.) 

M. Nasal wash. 
A spray containing five grains of menthol to an ounce of Menthol and 
albolene (0.3 to 32) is always very grateful in relieving the albolene 
sense of fullness and the headache. Cocaine, which should be 
used very carefully in the fully developed attack, may occa- Cocaine 
sionally serve a useful purpose if it is insufflated in the form 
of a powder in combination with menthol. A useful preparation 
of this kind is the following: 

Menthol, 

Cocaine, of each, 0.3 (gr. 4%) 

Zinc sozoiodate, 

Boric acid, of each, 10.0 (5 2%) 

M. Sig. For nasal insufflation. 

Adrenalin, in 1 to 1*000 solution, may also be employed Adrenalin 
locally to give relief. 

All these remedies, recommended for local use, should be 
used only if it becomes necessary to remove excessively distress- 
ing subjective symptoms for the time being; they should not, 
however, be given too energetically in any case, for their violent 
vaso-constrictor action gradually produces paralysis of the vaso- 
motor nerves, with permanent dilatation and serious injury to 
the nasal mucosa, leading in its ultimate consequences to a pro- 
longation of the acute attack and the establishment of sub-acute 
or chronic catarrhal conditions within the nose. 



CORYZA VASOMOTORIA AND HAY FEVER. 

Vaso-motor coryza is distinguished from catarrhal rhinitis Definition 
by the fact that the secretion always remains watery and never 
becomes purulent. To this category of rhinitis belongs hay fever 
and pseudo hay fever; the former being produced chiefly by 
the pollen of Ambrosia artemisi folia; the latter by a variety 
of other floating particles of vegetable origin. Vaso-motor Hay fever and 
coryza usually affects neurotic individuals. After exposure to a P seudo kay 
draft they suddenly begin to sneeze violently while a profuse 
amount of clear watery fluid pours from the nose. The attack 
is usually of short duration. Occasionally, however, unless 
rapidly aborted, it leads to true catarrhal rhinitis. To abort 



270 



CORYZA VASOMOTORIA AND HAY FEVER 



Abortive 
treatment 
Morphine and 
atropine 



Prophylaxis of 
hay fever 



Opium and 
belladonna 



Menthol-cam- 
phor 



the attack one-twenty-fourth grain of morphine with one-two- 
hundredth grain of atropine should be given every two hours 
for four or five doses. Local applications do no good what- 
soever. 

The treatment of hay fever and of pseudo hay fever is a 
very ungrateful task when the attack is once established. An 
intelligent prophylaxis, however, may aid very much towards 
preventing the recurrence of attacks of hay fever, or at least 
towards rendering the seizures less severe and less protracted. 
In the first place the mucous lining of the nose must be carefully 
treated during the winter, hypertrophies, varicose veins, deform- 
ities, etc., being corrected. More important than this, however, 
is the treatment of the underlying neurotic, i. e., neurasthenic or 
hysteric, temperament. Here, hydrotherapeutic measures, a 
course of arsenic or strychnia or phosphide of zinc, and all the 
measures described in detail in the Section on Gastric Neuroses 
have an important place. Sufferers from hay fever, as is well 
known, obtain the greatest relief, or even complete immunity 
from attacks, by a change of climate. Most mountain climates 
and the shores of Lake Superior, Lake Huron and the northern 
shores of Lake Michigan enjoy a well merited reputation as hay 
fever resorts. 

Symptomatically, in order to reduce the violent coryza, the 
conjunctivitis and the asthma in patients who cannot go away, 
opium and belladonna, in two or three drop doses of the tinc- 
tures, may be given three or four times a day. Often small 
doses of atropine, one-two-hundredth grain, are useful, also 
given three or four times a day. The menthol-cocaine mixture, 
described on page 269, may be inhaled, or smelling salts of 
the following formula be used with considerable relief to the 
patient : 



Carbolic acid, . 30 drops 

Ammonium carbonate, 1 ounce 

Charcoal powder, 1 ounce 

Lavender oil, 20 drops 

Compound tincture of benzoin, V 2 ounce 
M. Sig. Smelling salts. 

— (Lennox Browne.) 

Sprays Sprays of adrenalin, morphine, salicylic acid, cocaine, cap- 

sicum, etc., have all been recommended, but their effect is very 
transitory and, as a rule, injurious to the nasal capillaries, es- 
pecially if used continuously. Their use had best be eschewed 



EPISTAXIS 271 

altogether or reserved for emergencies when it becomes neces- 
sary to grant temporary relief. The use of Dunbar's "Hay Dunbar's hay 
Fever Serum" is still in the experimental stage, but promises fever serum 
something. It is too early to render judgment in regard to its 
efficacy. 



EPISTAXIS. 

Nose-bleed is an important symptom of manifold origin that Epistaxis of 
the internist is frequently called upon to treat. Those forms ^^ nical 
of epistaxis that are due to mechanical injury of the blood ves- 
sels of the nasal mucosa of necessity call for topical or surgical 
treatment. To this category belong cases of epistaxis that follow 
trauma, especially fracture of the base of the skull, rupture of 
the sinuses, etc. ; epistaxis occurring as a complication of tumors, 
malignant or otherwise, of the nose or its accessory cavities 
whose surfaces within the nose undergo ulceration with result- 
ing erosion of superficial arteries; and epistaxis from ulcers of 
the nasal cavity due to syphilis, lupus and other causes. 

In addition to this mechanical form there are important Epistaxis of 
forms of epistaxis that are due to constitutional causes. In the origin* 1 10na 
first pluce any of the manifestations of the hemorrhagic diathe- 
sis, notably hemophilia, scurvy and purpura, as well as any of 
the severe anemias and leukemia, can produce hemorrhage from 
the nose. Here the hemorrhage is rarely profuse but generally 
consists of slow and continuous oozing with the formation of 
large clots and hematomata. In most of these cases one must 
assume that diapedesis of blood occurs through vessel walls 
weakened and rendered permeable to blood plasma and corpus- 
cles by nutritional disorders of their tissues ; now and then these 
degenerative changes produce fragility and rupture of arterioles 
with more profuse bleeding. 

To the same class undoubtedly belong those forms of nasal Epistaxis in 
hemorrhage that occur as a part phenomenon of various infec- intoxicSions 
tions and intoxications. Thus in typhoid fever, in most of the ex- 
anthemata and in yellow fever, nose-bleed is common ; in hepatic 
cirrhosis and acute yellow liver atrophy, also phosphorus liver, 
in gout and in diabetic acidosis epistaxis may occur. The exact 
explanation of this phenomenon is still forthcoming, presumably, 
however, one is dealing with degenerative processes occurring in 
the vessel walls superinduced by the action of circulating bac- 
terial toxins or of poisonous products of perverted metabolism. 

A third variety of cases of epistaxis occurs in diseases of Epistaxis in 
the cardio-vascular apparatus accompanied by high arterial cardio-vascu- 
pressure with fragility of blood vessel Avails or profound venous lar apparatus 



272 



Epistaxis and 
sexual dis- 
orders 



Topical treat- 
ment 



Ice compress 
and ice water 
injections 



stasis as, for instance, in arterio-sclerosis, in syphilitic arteritis, 
chronic alcoholism, and lead-poisoning. 

In valvular diseases of the heart in the stage of decompen- 
sation, or in tricuspid lesions before the balance of compensation, 
is broken, hemorrhage from profound venous stasis about the 
nasal mucosa is apt to occur. In this group of cases hemorrhage 
from the nose rarely takes place spontaneously but is usually 
superinduced by some straining effort; so that hiccough, bron- 
chitis, emphysema, nausea, vomiting from whatever cause, con- 
stipation and all other disorders that force the patient to strain 
must be considered determining causes of nose-bleed in predis- 
posed subjects. 

Finally there is an interesting class of cases of epistaxis re- 
lated to disorders about the sexual apparatus. It is well known 
that irritation of the sexual sphere can produce turgescence of 
the corpora cavernosa of the turbinates; that inversely stimuli 
applied to the nose influence the sexual sphere, so that certain 
odors exercise a peculiarly stimulating effect upon the libido 
sexualis; that treatment of the nose, especially cocainization 
of certain sensitive areas, can occasionally exercise a profound 
effect upon dysmenorrhea. It is not surprising, therefore, to 
find nose-bleed occurring not infrequently as a part phenomenon 
of disorders of the sexual sphere. Epistaxis is a common accom- 
paniment of excessive masturbation; it is especially frequent 
during the age of puberty in individuals of both sexes and it 
not infrequently accompanies menstruation or takes its place, 
so that it has been characterized in these instances as a vicarious 
form of menstruation. 

To treat epistaxis, especially chronic recurrent or particu- 
larly obstinate, continuous forms of the disorder, successfully 
all these causative factors must be thought of, the exact etiology 
determined and causal treatment instituted accordingly. 

Epistaxis due to purely local causes, violence, trauma, tumor, 
ulceration, chronic nasal catarrh with erosion of arterioles, calls 
for appropriate topical treatment. In post-operative and trau- 
matic nose-bleed it is a good general rule not to be in too great 
a hurry to stop the nasal hemorrhage by active interference, as 
most cases of traumatic epistaxis have a tendency to become 
spontaneously arrested, and the hemorrhage is rarely so pro- 
fuse as to endanger life; with the loss of blood, moreover, the 
coagulability of the blood increases. The simplest measures that 
should be tried, if the hemorrhage does not cease spontaneously 
within a reasonable time, are the application of ice to the out- 
side of the nose (pressing a piece of ice against the side of the 
nose near the bridge) and the injection of ice water into the 



EPISTAXIS 273 

bleeding nasal cavity. If possible tampons should be avoided 
in these cases, as they are exceedingly disagreeable to the patient 
during the days they have to remain in place and may cause 
new bleeding from tearing of the clot or cicatrix when they 
are removed. 

If the hemorrhage is very profuse and the patient becomes Cauterization 
rapidly exsanguinated so that one is justified in assuming that g** 116 bleedm £" 
an artery has been ruptured or eroded, then every effort should 
be put forward to find the bleeding spot. If the bleeding area 
can be located, after cleansing the nose of blood, it should be 
touched with trichloracetic acid, a stick of silver nitrate, tannin 
powder or a strong solution of hydrogen peroxide or, if neces- 
sary, with the actual cautery, remembering always that the latter 
should be removed while hot, as otherwise the clot becomes ad- 
herent to the instrument and may be torn off again. 

If it is impossible to stop the hemorrhage in this Way, then Tamponade 
tamponade of the nose becomes necessary. The application of 
the simple aseptic cotton, or better still, of iodoform gauze, 
should be preferred to the use of cotton saturated with cocaine 
(5 per cent.) or antipyrin (10 per cent.) or ferric chloride 
solutions; especially the latter should be avoided for its styptic 
effect is slight, the clot that is formed is very fragile and, above 
all, the tampons become very slippery and are apt to drop out. Digital com- 
Provided simple packing of the nose with cotton or iodoform P ression 
gauze, combined with digital compression from without, do not 
stop the bleeding, then it becomes necessary to plug the poste- 
rior nares with a Bellocq canula according to the methods de- Plugging of 
scribed in special works on disorders of the nose and throat and P° sterior nares 
in text books on. surgery. 

While these local measures are being applied the general General man- 
management of violent nasal hemorrhage is the following: The a §' ement 
collar or neck-band should be loosened; the patient should not 
be allowed to stoop over and should be put to bed in a semi- Position 
recumbent position with the head high or thrown back. Often 
holding the hands over the head is a useful measure. It may 
become necessary to ligate off the extremities with bandages in 
order to reduce the volume of blood streaming to the head. If Ligating ex- 
the blood pressure falls from loss of blood and the pulse be- remities 
comes small and weak, a hypodermic injection of camphorated 
oil, or of camphor in ether, or of ether alone, must be given for Supporting the- 
their analeptic effect (see page 32). The management of post- heart 
hemorrhagic anemia is fully described on page 7b*. 

In the other forms of nose-bleed that are not due to injury Treatment of 
or erosion of larger blood vessels in the nose, the following plan fP^taxis in ar- 
of treatment should be adopted : In cases that are accompanied 



274 



by high arterial tension, notably in cases of cardio-vascular and 
renal disease, in syphilitic arteritis and arterio-sclerosis, an 
effort should always be made to discover the bleeding point in 
the nose. In the majority of cases the hemorrhage occurs from 
the septal artery at a spot near the anterior part of the sep- 
tum. In this region spurs are often found, so that here the 
mucosa is often attenuated and foreign bodies can also readily 
lodge and cause local erosions. While every attempt is being 
put forward to stop the hemorrhage locally by direct treat- 
ment of the bleeding spot (see above), by ice water injections, 
by packing with pledgets of cotton or iodoform gauze combined 
with digital compression and the application of ice externally; 
Aconite while the patient is instructed to hold his arms over his head 

Veratrum and to follow the other general rules in regard to position that 

have been described above; an attempt should also at once be 
made to lower the blood pressure by giving drop doses of the 
tincture of aconite or of veratrum viride every half hour for 
three or four doses, or better still by giving one single dose of 
three to five drops of aconite tincture in water at once, fol- 
lowed later by one-hundredth grain doses of nitroglycerin, re- 
peated once or twice, or by one dose of one grain (0.05 gm.) of 
erythrol tetranitrate. 

If the blood pressure is not high and if the epistaxis is due to 
simple oozing from congested veins or from rupture of venules 
or capillaries on the surface of the nasal mucosa, and if this 
venous congestion is due to decompensated heart lesions, or tri- 
cuspid insufficiency without decompensation, then the use of 
digitalis in five drop doses of the tincture, repeated three or 
four times at one hour intervals or, better still, of camphor, 
ether, ammonia or other analeptics (for exact mode of adminis- 
tration, see page 32), is indicated. Here the patient shouM sit 
up and place his feet in hot water medicated with mustard, about 
three or four teaspoonfuls to a gallon of water. 

The best internal remedy aside from cardiac tonics is hy- 
drastis in twenty to thirty drop doses of the tincture, repeated 
several times, or as hydrastinine hydrochlorid in doses of one- 
half to two grains (0.03 to 0.13 gm.), in watery solution, by mouth 
or hypodermically. Cotarnine (stypticine) in the dose of one- 
third to one-half grain (0.02 to 0.03 gm.) may be administered 
in the same way. Combined with these measures simple local 
treatment with ice water, digital compression and, if necessary, 
Venesection packing with cotton may be tried. Sometimes, too, venesection 

and the withdrawal of 200 to 300 cc. of blood is a very useful 
procedure. If the bleeding from the nose occurs frequently in 
such cases and if it is generally superinduced by some strain- 



Nitroglycerin 
Erythral te- 
tranitrate 

Treatment of 
epistaxis due 
to venous 
stasis 



Digitalis 
Analeptics 



Mustard foot 
"baths 

Hydrastis 
Cotarnine 



EPISTAXIS 275 

ing effort then all the factors that determine the straining, i. e., 

coughing, vomiting, hard defecation, should be removed and Avoidance of 

appropriate treatment undertaken against any underlying efforts 115 

chronic respiratory or gastro-mtestinal disorder that may 

be present. 

A word of warning may be expressed in this place against Dangers of 
the use of ergot in nose-bleed. This drug is commonly recom- erg,ot 
mended for the arrest of hemorrhage anywhere in the body, 
and while it is of marked value in the arrest of uterine hemor- 
rhage, it is doubtful whether it is efficacious in epistaxis. I 
believe it does more harm than good in nose-bleed, even in those 
cases in which it is desired to cause constriction of bleeding 
arteries; in all the other cases of nose-bleed in which the hem- 
orrhage occurs from bleeding veins and capillaries, or in which 
the hemorrhage is due to diapedesis of blood through degener- 
ated vessel walls, its use is at least superfluous, for ergot usually 
produces a slight rise of the blood pressure. Ergot, moreover 
produces blood vessel constriction only in certain definite 
areas and the nasal mucosa does not happen to be one of the 
regions in which the drug exercises this effect on the vascular 
supply. As a matter of fact I have never been satisfied that 
it acts beneficially in nose-bleed or in pulmonary hemorrhage 
(see also page 310). 

Opium and morphine and members of the chloral group opium 
should also always be avoided in treating cases of nasal hem- Morphine 
orrhage. The temptation to give these remedies is great as the Chloral not to 
patients are often restless and frightened and one might think 
of giving them as sedatives in order to quiet this excitement. 
Opiates, however, reduce the tone of the vaso-motor center in 
the medulla and hence cause vaso-dilation and consequently 
congestion, especially about the head. Witness the flushing of 
the face after the exhibition of opiates, that renders them de- 
cidedly harmful in hemorrhages from the nasal mucosa (see 
also page 310). The drugs of the chloral group exercise a simi- 
lar effect, for they too produce paralysis of the vaso-motor nerves 
and induce peripheral congestion. 

The causal treatment of nasal hemorrhage, due to anemia, causal treat- 
leukemia, various infections, auto-intoxication in hepatic and ment in infec- 
gastro-intestinal disorders and in poisoning by different drugs is t ]^l gpis- 
in all particulars the same as the treatment of the underlying taxis 
disorders and need not be discussed again in this place. It is 
frequently difficult to determine whether the nose-bleed is due 
to the toxemia direct, i. e., to changes in the composition of the 
blood, or to degenerative changes in the vessel walls of the 



276 



ACUTE LARYNGITIS 



Epistaxis often 
a useful oc- 
currence 



Bleeding as a 
prophylactic 
against vicari- 
ous epistaxis 



Leeches to the 
anus 



Sitz baths and 
drugs to pro- 
duce menstru- 
ation 



nasal mucosa, or to general cardio-vascular changes (high blood 
pressure, venous stasis, etc. ) produced by the circulating poisons. 

It is well to remember that occasionally nose-bleed is a useful 
means adopted by Nature to relieve plethora, especially in in- 
dividuals suffering from stasis due to decompensated heart 
lesions and in subjects of an apoplectic habit. Here the shed- 
ding of blood from the nose is a safety-valve action and one of 
Nature's means of defense against more serious injury. In such 
instances the physician must frequently exercise his best judg- 
ment in regard to the advisibility of stopping the hemorrhage 
at once or of allowing some blood to escape before endeavor- 
ing to arrest the flow. If the conditions are such that venesec- 
tion would have been indicated, then no effort should be made to 
stop the nose-bleed too soon. 

By the same sign bleeding the patient from the arm may 
occasionally be efficacious in forestalling disagreeable vicarious 
menstruation from the nose. In some of these cases hemorrhoidal 
bleeding occurs instead of epistaxis, so that if it is desired to 
stop or prevent the nose-bleed, leeches to the anus often accom- 
plish this purpose if leeching is performed immediately before 
and during the time of the menstrual period. Hot vaginal 
douches or a hot sitz-bath; free evacuation of the bowels by a 
saline laxative: tincture of cimicifuga, in five drop doses, every 
four hours, during the two or three days preceding the expected 
menstruation, Pil. Aloes et Ferri five grains (0.3 gm.) two or 
three times a day, or Pil. Aloes et Myrrha in the same dose, occa- 
sionally aid in overcoming the amenorrhea and in preventing 
vicarious epistaxis. 



Abortive 
treatment 



Expectorants 



ACUTE LARYNGITIS. 

The prophylactic and internal treatment of acute laryngitis 
is essentially the same as that of acute rhinitis and pharyngitis 
(page 265). Upon the first appearance of the prodromal symp- 
toms, sweating, mustard foot baths and the combination of 
quinine, Dover's powder and aspirin, as described on page 268, 
with hot whisky lemonade should be given. The bowels should 
be thoroughly evacuated upon the onset of the attack by the 
use of calomel given in one-tenth grain doses for ten doses in 
the evening, and followed in the morning by a tablespoonful of 
magnesium sulphate in water. 

As soon as secretion becomes established mild expectorants 
(see page 281) may be given. The following expectorant mixture 
is very useful : 



ACUTE LARYNGITIS 277 

Ammonium carbonate, 5 grains 

Tincture of scilla, 10 drops 

Compound tincture of camphor, 15 drops 

Syrup of ginger, 1 drachm 

Infusion of serpentaria, q. s., 1 ounce 
M. Sig. Expectorant mixture. 

— (Browne.) 

A very practical adjuvant to the treatment and one that 
alone, better than any other means, often suffices to bring about 
quick relief and to hasten restitution to normal conditions, is cold 
about the throat applied by means of the Leiter coil or a hand- Cold compress 
kerchief wrung out of cold water, placed tightly about the 
throat and covered with a woolen or flannel bandage. It may 
be left on over night and renewed again in the morning; or, 
if the patient remains at home, applied several times during the 
day. 

The atmosphere of the room should be saturated with mois- 
ture from a steam kettle. Inhalations of steam medicated with 
equal parts of a mixture of oil of terebinth, juniper and eucalyp- Moist atmos- 
tus, or compound tincture of benzoin, may be used as follows: P nere 
A teaspoonful of the mixture of the three oils, or of the ben- 
zoin, is mixed with a quart of boiling water in a dish; the 
patient's head and the dish are covered with a thick cloth and 
the rising vapors inhaled deeply for five to ten minutes at a inhalations 
time, three or four times a day. Or the inhalations may be made 
through a paper cornucopia, the large end of which is 
held over the dish of hot water. Special steam inhalers may 
also be used to advantage and here any of the etherial oils men- 
tioned above, particularly oil of terebinth, the oleum pumilionis, 
or the oil of juniper are useful. In case of severe pain and dif- 
ficulty in swallowing ten to fifteen drops of opium tincture may 
be added to the inhaling fluids. 

In the later stage of the disease when the mucus becomes 
tough and difficult of expectoration, inhalations through a steam 
vaporizer of a 1 to 2 per cent, solution of common salt, or of 
sodium bicarbonate, are exceedingly useful, and here again the 
addition of a few drops of opium tincture will relieve the sore- 
ness in the throat better than any means that I know of. 

Intra-laryngeal applications are rarely necessary unless there intra-laryngeal 
is very great hoarseness, or much pain with burning and dry- applications 
ness and difficulty in swallowing. A useful laryngeal spray con- 
taining cocaine and bromide of potash, is the following: 



278 



ACUTE LARYNGITIS 



3 



Insufflation 
of alum 



Cleansing the 
nasal passages 



Muriate of cocaine, 
Bromide of potash, 
Distilled water, 
M. 



0.03 

10.00 

300.00 



Better still, however, is the insufflation of a powder consist- 
ing of equal parts of alum and sugar of milk. The latter should, 
however, only be used as an emergency measure to stop hoarse- 
ness and aphonia in an individual, for instance, who has to use 
his voice for two or three hours despite the existence of laryngeal 
catarrh. 

Symptomatically, the thorough cleansing of the nasal 
passages with an alkaline wash, followed by a menthol and 
alboline spray, as described under Rhinitis, is often followed 
by good effects upon the laryngitis. 



CHAPTER VII. 



DISEASES OF THE BRONCHI, LUNGS AND 
PLEURA 

I. DISEASES OF THE BRONCHI. 
ACUTE TRACHEO-BRONCHITIS. 

In acute catarrhal bronchitis there is always, first, hypere- 
mia of the mucous lining of the bronchial tubes followed by de- 
generation of the superficial epithelia, then an outpouring of 
a serous transudate with swelling of the mucosa and narrowing 
of the lumen of the bronchial tubes and, last, loosening and 
desquamation of the epithelia that have undergone degeneration. classlfi cation 
Clinically, it is convenient to distinguish two stages, viz., what 
may be called a dry and a wet stage, the former being the stage 
of hyperemia, the latter the stage of profuse exudation of serum 
and casting off of degenerated epithelium. The object of the 
treatment in acute bronchitis must be, if possible, to abort the 
attack while it is still in the dry, hyperemic stage, or, if this 
fails, to convert the first into the second stage as rapidly as 
possible. 

Prophylaxis can be exercised merely in rendering the indi- Prophylaxis 
vidual less susceptible to temperature changes or other ex- 
traneous influences that determine bronchial catarrhs. Here 
the same rules in regard to clothing, diet, bathing, exercise, etc., 
obtain as in the prophylactic treatment of catarrh of the upper 
respiratory passages, and I refer to the chapter on these dis- 
orders for the details. 

Upon the onset of the first signs of bronchial catarrh, viz., Abortive 
a sense of dryness, irritation or pain behind the sternum and 
along the distribution of the larger bronchial tubes, a saline lax- 
ative should be administered and the patient should take a 
dose of three grains (0.2 gm.) of quinine sulphate, and drop 
doses of the tincture of aconite every hour for five or six doses. 
Hot lemonade, with a tablespoonful of brandy or whisky to the 
tumblerful, should be freely taken. A general hot bath of 100° 
to 105° F., provided the patient can go to bed afterwards and 
sweat between woolen blankets, is very useful. Turkish baths, 
which are very popular, are dangerous unless the patient can 
remain in the bath establishment over night. It is rarely nec- 
essary to give pilocarpine to produce sweat, as the hot bath, with 
hot alcoholic drinks, possibly a ten-grain Dover's powder, suf- 



treatmeat 



280 



ACUTE TRACHEOBRONCHITIS 



The treatment 
of the dry 
stage 



Inhalations 



Bronchitis 
tent 



Opiates 



Atropine series 



Alkalies 



Counter-irrita- 
tion over the 
■chest 



fice to produce the desired vaso-dilator and diaphoretic effect. 
After an hour or two of profuse sweating the patient should be 
carefully dried and put back to bed between dry, warmed linen 
sheets. 

If these measures do not abort the attack, then every effort 
should be put forward to soothe the inflamed mucosa and, at the 
same time, promote outpouring of fluid from the bronchi; in 
other words, to relieve the dryness and hasten the development 
of the second stage. This object can be accomplished by in- 
halations, the use of opiates and alkalies internally, and stim- 
ulating compresses externally. 

Inhalations of physiological salt solution, or of 2 to 3 per 
cent, sodium bicarbonate solution, through a steam inhaler are 
very useful. Instead of using a steam inhaler the patient may 
hold his head, covered with a cloth, over a dish of boiling water, 
to which may be added tincture of benzoin (one drachm to one 
pint), a few drops of opium tincture, or of extract of bella- 
donna; the latter especially if the cough or the retrosternal pain 
is very severe. In children the bronchitis tent serves a very 
useful purpose. It is constructed by hanging over the bed 
sheets supported either by a special rack or by a screen. Within 
the tent a kettle of water is kept boiling by means of an alcohol 
lamp. In this way the child continuously breathes air that is 
saturated with moisture, and a very soothing effect upon the 
inflamed mucous membranes of the bronchial tubes can be ob- 
tained in this simple manner. 

Internally some opiate will generally have to be given to 
allay the cough, preferably morphine, in the dose of one-thirty- 
second to one-twelfth of a grain, or codeine one-sixteenth to 
one-fourth grains. The numerous other opium derivatives, as 
heroin, dionin, peronin, etc., possess no advantages over mor- 
phine and codeine. Hyoscyamus, stramonium, belladonna and 
other members of the atropine series are best reserved for the 
stage of profuse secretion, for while they act as sedatives and 
relieve bronchial spasm they also check secretion and the latter 
effect is undesirable during the dry stage of bronchitis. Alka- 
lies, administered in the form of citrates, acetates or carbonates 
of potassium or sodium, in doses of ten to thirty grains (0.6 to 
2 gm.) at four or five hour intervals, in milk or water, or in the 
form of mineral waters, act very beneficially at this stage. It 
is possible that they are in part excreted by way of the bron- 
chial mucosa hence causing some irritation with outpouring of 
secretion. Their exact mode of action is not all understood, but 
empirically we know that they act very beneficially. 

One of the most useful adjuvants to the treatment of this 
stage of bronchitis is counter-irritation over the chest, preferably 



ACUTE TRACHEO-BRONCHITIS 281 

administered by the use of cold compresses. A linen bandage 
about three yards long and six inches wide is dipped into water Cold compress 
of room temperature and thoroughly wrung out. One end of 
the binder is applied to the right axilla, the binder carried across 
the chest to the left shoulder, across the back to the right axilla, 
across the chest to the left axilla, across the back to the right 
shoulder and then to the middle of the chest. A second cross 
bandage of dry flannel is then applied over the first one and the 
dressing left in place until it is dry, which usually requires four 
or five hours. A second wet pack may then be applied, or the 
skin may be washed with alcohol and rubbed dry. It is unnec- 
essary to apply an impermeable oil-silk or rubber dressing over 
the wet bandage; if the binder is to be left on all night the 
patient may wear a woolen shirt rather than a flannel bandage piaster, cup- 
over the cross bandage. Mustard plasters, dry cups, iodine and P in g"> lodine » 
camphorated oil, are not as effective as this simple means. 

As soon as the dry, hyperemic stage is over and an exudation Treatment of 
of mucus from the bronchial mucosa has begun, then the treat- the wet sta » e 
ment becomes radically different. Three main indications must 
now be met, namely, first, to promote liquefaction of the sputa; 
second, to aid their expulsion ; third, to allay excessive cough- 
ing and to relieve the pain in the chest. 

A number of remedies can be employed to produce liquefac- Liquefaction 
tion of the sputa. As already indicated above, alkaline or saline of the s P uta 
waters serve this purpose. They should be taken warm at fre- Alkalies 
quent intervals and in abundant quantities, either alone or mix- 
ed with milk. 

Probably the most useful remedy in this condition is chloride 
of ammonium. It is not improbable that this drug is in part Ammonium 
excreted via the bronchial mucosa, so that it acts locally as a chloride 
slight stimulus to the bronchial epithelia and produces a reac- 
tive outpouring of serum ; besides, ammonia salts exercise a 
stimulating effect upon the respiratory centres in the medulla 
and hence aid in the expulsion of the mucus. The dose of am- 
monium chloride varies from five to fifteen grains (0.3 to 1 
gm.)and it should be given at three or four hour intervals. A 
very convenient and useful way of administering it is in solu- 
tion in Mist. Glycrrhiza? Comp. (see page 28o i. 

Emetics, given in small doses, produce a copious transuda- Emetics 
tion of bronchial mucus and of saliva. They are all very useful, 
therefore, if the bronchial secretion is tough and viscid and thus 
difficult of expectoration, but they should never be used when 
the secretion of the bronchial tubes is abundant. Nor should ipecac 
they ever be given to sufferers from heart disease (see page 



282 



ACUTE TRACHEOBRONCHITIS 



Apomorphine 
Tartar emetic 

Turpentine 



Terpene hy- 
drate 



Terpinol 



Balsams of 
Peru and tolu 
Sodium ben- 
zoate 



Volatile oils 
Copaiba 



Cubebs 
Santal oil 



Strychnia 



38) or from catarrh of the stomach. The most useful mem- 
bers of this group are ipecac, most conveniently given in the 
form of Dover's powder, five grains, several times a day; or as 
syrup of ipecac in one-half to one teaspoonful doses; apomor- 
phine, given in doses of one-twentieth to one-tenth of a grain 
(.03 to .06 gm.) ; and tartar emetic, in doses of one-thirtieth to 
one-eighth grain, two or three times a day. 

Turpentine is also useful at this stage ; it should be given in 
ten to twenty drop doses in a tablespoonful of milk and half 
a glass of milk taken immediately afterwards. If the patients 
cannot take the milk, five to six drops of turpentine may be 
placed upon a piece of bread and butter and the drug taken in 
this way. The milk and the butter prevent the irritating effects 
of turpentine upon the gastric mucosa. Agreeable preparations 
of turpentine are terpene hydrate, which can be given in daily 
doses of 0.2 to 0.5 gm., acceptably in dilute alcoholic solution 
with some simple syrup; terpinol, in three grain doses, four or 
five times a day, in capsule with two or three parts of olive oil. 

The balsams of Peru and tolu are very popular in the treat- 
ment of bronchitis. They all contain benzoin or its derivatives, 
hence sodium benzoate belongs to the same group. Balsams of 
Peru and tolu should be given in an emulsion or as a mucilage 
in doses of five to fifteen grains (0.3 to 1 gm.) several times a 
day. The syrup of tolu is particularly useful as a vehicle for 
ammonium chloride, emetics or opiates, but it contains very 
little of the balsam so that it is itself practically inert. Ben- 
zoate of soda is generally very useful; it should be given in five 
to thirty grain doses (0.3 to 2 gm.) two or three times a day. 

Certain of the volatile oils, as copaiba, cubebs and santal, 
may also be given at this stage. Copaiba, in the form of the 
oleoresin, in capsule, in doses of ten to twenty drops (0.6 to 1.3 
cc. ) ; cubebs also as the oleoresin, in doses of ten to fifteen minims 
(0.6 to 1) ; and santal oil in the same dose, several times a day. 
Turpentine and the balsams are apt to irritate the stomach and 
the kidneys and hence they should be administered with care and 
their use discontinued at once upon the appearance of signs of 
gastric or renal irritation. 

In order to aid the expulsion of the mucus strychnia is one 
of the most effective remedies, for it causes contraction both of 
the bronchial musculature and of the large respiratory muscles. 
Strychnia is particularly valuable in cases of bronchitis in which 
much tough mucus accumulates during the night, so that the 
patients awake with severe dyspnea. Here the administration 
of one-thirtieth to one-fortieth of a grain of strychnia before 
going to sleep frequently prevents these attacks of nocturnal 



CHRONIC BRONCHITIS AND BRONCHIECTASIS 283 

dyspnea. Senega, finally, which may be given in doses of ten Senega 
to twenty drops (0.6 to 1.3 gm.) of the fluid extract, or in the 
form of the syrup of senega one to two drachms (4 to 8 gm.), 
may also occasionally be employed in this stage of bronchitis. 

If the cough is very severe and distressing then it becomes 
necessary to allay both the irritability of the coughing center and 
the local sensitiveness in the pharynx. This can best be done by Opium and 
small doses of opium or morphine, preferably given in combina- orp me 
tion with atropine or belladonna, especially if there is, at the 
same time, a very active and profuse discharge of bronchial Atropine 
secretion. 

One of the best standard preparations for internal use at this 
stage is the Compound Licorice Mixture containing opium, anti- Mistura 
mony, spirits of nitrous ether and licorice as its chief ingredients. C0 ^J TT 
It should be given in one to two teaspoonful doses, several times 
a day. In order to quiet the local irritation in the throat any Cough syrups 
demulcent or syrup is useful, and here the innumerable cough drops 
Irops and cough syrups that are recommended have their field 
of application. 



CHRONIC BRONCHITIS AND BRONCHIECTASIS. 

Chronic bronchitis may develop as a result of repeated at- 
tacks of acute bronchitis, or it may be a part phenomenon or 
complication of heart lesions, arterio-sclerosis, emphysema, 
obesity, gout, chronic nephritis and other disorders. The chronic 
inflammation of the bronchial mucosa generally yields to appro- 
priate treatment directed towards removing the underlying 
cause, as discussed in the section on these different diseases. If Causal and 
the primary affection is irremediable, or if mechanical destruc- treatment l ° 
tion, scil. atrophy of the mucous lining of the bronchi, has oc- 
curred, then the treatment of chronic bronchitis of necessity 
becomes symptomatic. The treatment of the different varieties 
of chronic bronchitis differs somewhat according to the charac- 
ter of the secretion. From a therapeutic standpoint it is practi- 
cal to distinguish a dry form of chronic bronchitis in which there 
is very little secretion; a moist form in which there is very 
abundant secretion; a form in which the exudate is fibrinous and 
in which casts of the bronchial tubes appear, and, finally, a 
purulent or putrid form of chronic bronchitis. 

In all kinds of chronic bronchitis the choice of climate is Climate 
exceedingly important. In the dry variety a moist, warm climate 
with the minimum of sudden temperature changes is the ideal, 
whereas in the moist variety a dry, hot climate is by far prefer- 
able. Whatever resort is selected the atmosphere should be free 



284 



CHRONIC BRONCHITIS AND BRONCHIECTASIS 



Mountains 
Seashore 



Hydrotherapy 



Alkaline and 
saline waters 



Sulphur waters 



Medicamentous 
treatment 



Treatment of 
putrid bron- 
chitis 



Inhalations 



from dust. If the subject is anemic, and if there is complicating 
lung trouble, especially of a tuberculous character, then a mod- 
erate altitude is advantageous (see page 318). If there is em- 
physema and the subject is not anemic, then the sea shore is 
better. The selection of a proper climate for chronic bronchitis 
is altogether an exceedingly difficult task, for it must be governed 
by many individual factors that vary in each patient. 

Hydrotherapeutic measures are of particular value in dry 
forms of chronic bronchitis and enough cannot be said in regard 
to their efficacy, especially of cold compresses applied in the 
form of crossed bandages, as fully described in the section 
on Acute Bronchitis (see page 281). These compresses allay the 
coughing, act as a general sedative to the respiratory centers, 
liquefy the bronchial secretions and aid in their expectoration. 
Alkalies and alkaline and saline waters are always of value; 
the latter both on account of their stimulating effect upon the 
bronchial secretion and their laxative properties; for they ef- 
fectively relieve abdominal plethora and hence save the right 
heart much labor, in this way improving the circulation in the 
lungs. Sulphur waters, too, have an important place in the 
treatment of chronic catarrhal bronchitis, for part of the sulphur 
is eliminated via the bronchi as sulphureted hydrogen, produc- 
ing in its passage active hyperemia of the atonic mucosa, hence 
improving the circulation in the bronchial wall and also acting 
to some extent as a local antiseptic. 

The drug treatment of chronic bronchitis varies according 
to the character of the secretion. In the dry variety remedies 
should be administered that can aid the liquefaction of the viscid 
mucus and, at the same time, stimulate the bronchial mucosa ; 
to this group belong ammonium chloride, turpentine, balsams of 
Peru and tolu, sodium benzoate, copaiba, cubebs, santal oil, 
ipecac, tartar emetic, apomorphine ; whereas in the moist variety 
drugs shou]d be used that can diminish the excessive secretion 
and simultaneously favor its expectoration, notably, belladonna, 
atropine, stramonium, hyoscyamus. All these remedies, with 
their dose and mode of administration, have been fully men- 
tioned under Acute Bronchitis. 

In purulent and putrid bronchitis, disinfection and deodoriza- 
tion of the foul bronchial secretion can be accomplished either 
by the inhalation of medicated vapors or by the internal admin- 
istration of different drugs that are in part excreted via the 
bronchi. The best method of treating the bronchial mucosa by 
inhalations is by means of a steam atomizer, using turpentine 
oil, tincture of eucalyptus, carbolic acid (1 to 3 per cent.), thymol 
(1 to 2.000), creosote or gnaiacol (1 to 2 per cent.), to medicate 



CHRONIC BRONCHITIS AND BRONCHIECTASIS 285 

the vapors. For internal use the balsams of Pern and tolu, 
sodium benzoate, turpentine and its derivatives (see index), Drugs 
fluid extract of eucalyptus, fifteen to thirty drops, or eucalyptol, 
five to fifteen drops, repeated several times a day (or sulphur 
waters), may all be employed. 

In fibrinous bronchitis the most effective remedy is iodide Treatment of 
of potash, given in increasing doses, beginning with ten drops fibrinous bron- 
of the saturated solution in milk, three times a day, and grad- 
ually increasing the dose until sixty or more drops a day are i di ae f 
being taken. The good effects from iodide of potash may pos- potash 
sibly be attributed to the fact that many cases of fibrinous bron- 
chitis are due to syphilis. Inhalation of lime water through a Lime water by 
steam atomizer is the best remedy to produce loosening and ex- m a a 10n 
pectoration of the fibrous coagulates in the bronchi. 

In many cases of chronic bronchitis it becomes necessary at Narcotics 
some stage of the disease to administer narcotics in order to 
check the severe cough. This is necessary for the comfort of 
the patient and in order to prevent emphysema and dilatation 
of the heart, two complications that are certain to' supervene 
unless the coughing is controlled. In view of the chronic char- 
acter of the disease particular care should be exercised not to 
create an opium habit, and, for this reason, it is well to fre- 
quently change both the preparations of opium as well as their 
mode of administration, giving at different times opium in tinc- 
ture or extract, morphine, codeine, heroin, dionine by mouth, 
hypodermically, in suppository or as a rectal injection. The 
dose should always be small and it is best if the patient does 
not know what he is getting. The addition of belladonna or Atropine 
atropine to opium preparations is usually of value. Strych- 
nine also has a place in the treatment of chronic bronchitis, for strychnine 
it aids expectoration by its stimulating effect upon the bronchial 
musculature, the respiratory centre and the heart. 

BRONCHIECTASIS. 

Bronchiectasis may well be discussed in connection with 
chronic bronchitis, for the internal treatment and the treat- 
ment by inhalation is essentially the same as in the putrid bron- 
chitis. In bronchiectasis certain mechanical features that 
characterize this disorder must be considered; thus the evacua- 
tion of the bronchiectatic cavities is promoted by placing the 
patient every morning in such a position that the opening into 
the bronchiectatic cavity, provided there is only one large cavity, Position of pa- 
points downward. In giving inhalations with the different rem- in^iati^ns^ 
edies described above it is always well first to produce evacuation 
of the cavity in this way and then to let the patient remain in 
the proper position while inhaling ; if this is done, the medicated 
vapor can come into much more intimate contact with the dis- 



l>8(i 



BRONCHIAL ASTHMA 



Danger of 
narcotics 



Operative 
treatment 



eased cavity wall than if the latter is full of excretion. In bron- 
chiectasis narcotics should be withheld, for if the sensibility of 
the mucosa near the orifice of the cavity or cavities is dead- 
ened, the normal coughing effort that results from contact of 
the putrid material with this area is prevented so that stagna- 
tion of the material in the bronchiectatic cavities is favored and 
the disorder is apt to be aggravated rather than improved. 

The operative treatment of bronchiectasis is still in the ex- 
perimental stage. Aspiration of bronchiectatic cavities is feas- 
ible only if the exact location., of the cavity can be determined by 
physical examination and if the cavity is near the surface. 
Drainage of the cavity by aspiration, and injection of antisep- 
tic fluids into the cavity, is never without danger ; this procedure, 
moreover, is followed by very indifferent results, and as there is 
generally more than one bronchiectatic cavity, it is hardly prac- 
ticable. Opening t'he pleura for the purpose of producing col- 
lapse of bronchiectatic cavities has been extensively practised; 
but I have not been convinced in those cases in which I could 
study the patients before and after the operation, that the re- 
sults obtained were sufficiently satisfactory to justify so pre- 
carious an inroad. 



Cardiac, renal, 
uremic, lead, 
e*~ M asthma 



Bronchial 
asthma 



Causes 



BRONCHIAL ASTHMA. 

Many forms of dyspnea that are due to heart disease, ne- 
phritis, obesity, diabetes, goutiness and lead-poisoning are com- 
monly included under the name of asthma, with various pre- 
fixes such as cardiac asthma, renal asthma, uremic asthma, lead 
asthma, etc. These symptomatic forms of asthmatic dyspnea 
usually yield to proper causal treatment directed towards the 
underlying disorder. 

Bronchial asthma proper is a disease sui generis, of various 
etiology. It is characterized by spasm of the bronchial mus- 
cularis, generally accompanied by vaso-motor disturbance in 
the bronchial mucosa, manifesting itself by hyperemic swelling 
and narrowing of the bronchial lumen, and occasionally by the 
formation of an exudate in the smaller bronchioles. 

These conditions may be produced, first, by local agencies 
directly affecting the upper respiratory passages and the bron- 
chial mucosa, as certain forms of dust or pollen and, in pre- 
disposed subjects, emanations from certain animals, as well as 
other odors; second, by certain psychic factors, as a fright or 
an emotional shock, a loud noise, a flash of light and many 
bizarre causes, especially in hysteric and neurasthenic subjects; 
third, by reflexes starting from variuos organs of the body, 



BRONCHIAL ASTHMA 287 

notably, the genital sphere, the gastro-intestinal tract (disten- 
sion of the stomach, constipation, meteorism and intestinal para- 
sites) and, above all, the nasal mucosa. 

Causal treatment should take all these elements into consid- Causal treat- 
eration. It is one of the fundamental rules in the treatment ment 
of bronchial asthma to carefully elicit from the patients state- 
ments in regard to those factors that seem to precipitate the 
attacks; and however ridiculous the determining elements may 
seem to be, to take the statements of the patient very seriously 
into consideration and to proceed accordingly. The element of 
suggestion is very strong in many cases, particularly in hysteri- 
cal women who have preconceived notions in regard to the ele- 
ments that produce asthma. To ridicule their belief is bad Suggestive 
practice and in such cases, suggestion, even hypnotism, is use- rea men 
ful; Christian Science has celebrated some of its greatest tri- 
umphs in the cure of such neurotic forms of bronchial asthma. 
In neurasthenic individuals judiciously applied hydrother- 
apeutic measures, as described in the Section on Gastric Neuroses, 
are exceedingly useful ; if possible such patients should be treated 
for a time in an institution, where any ovarian or uterine trouble 
may coincidentally be corrected. 

The diet should always be carefully regulated. Over- Diet 
loading the stomach, particularly with starchy foods, should 
studiously be avoided. Constipation and flatulency should be Constipation 
combated with the means that are discussed under Intestinal 
Diseases. Intestinal parasites should be sought for, and if found, Parasites 
removed. The patients should be advised against going to bed 
during the period of active gastric digestion, in other words, 
they should never take a heavy meal at night, nor indulge in 
late suppers. 

Treatment of the nose, while occasionally followed by very Nasal treat- 
gratifying results in bronchial asthma, is, by no means, the 
panacea that it is claimed to be by extremists. It . : s good prac- 
tice in every case of bronchial asthma to carefully examine the 
nose. The mucosa should be cocainized and sensitive areas, so- 
called 'asthma points," looked for by touching different intra- 
nasal areas with a probe. If marked respiratory reflexes can 
be elicited by touching such points, and especially if they are 
found upon a polypus or hypertrophied or turgescent tissues, 
then these over-growths should be removed. At all events the 
"asthma points" should be cauterized surgically. It is said 
that if true "asthma points" have been destroyed in this way, 
a febrile reaction will appear in the evening and persist for 
several days in susceptible individuals. If the patient will not 
give his consent to intranasal treatment t etween the attacks, then 
symptomatic relief can often be obtained during the paroxysm 



288 



BRONCHIAL ASTHMA 



Climate 



Interim, 
treatment 



Iodide of 
potash 



Arsenic 



Atropine 



by touching the "asthma points" in the nose with a five to ten 
per cent, solution of cocaine hydrochlorate. 

There is very little to say in regard to the selection of a climate 
for asthmatic subjects, for every patient is a rule unto 
himself. Some patients find relief at the sea shore, others at 
an altitude ; some in a moist, others in a dry climate ; a few 
people in the city and others in the country. It has been my ex- 
perience that most of the cases do well after any change of 
climate, so that they should be instructed to go to one place 
first, and to seek some other locality, high or low, wet or dry, 
hot or cold, as soon as the asthmatic paroxysms again make their 
appearance. Sufferers from hay fever asthma, of course, should 
select one of the resorts mentioned in the Section on Coryza 
Vasomotoria. 

It is very important to attempt by all means at our disposal 
to reduce the number of attacks; for in this way the affected 
centres are given a rest and are enabled to regain their normal 
tone. In the interim between attacks certain remedies should, 
therefore, be administered that may accomplish this purpose. 
The principal reliance can, I believe, be placed upon the iodide 
of potash, given in ten to thirty drop doses of the saturated 
solution in milk, three times a day, for three or four weeks con- 
tinuously, then omitted for a week and then again administered 
for a like period. Such an interrupted course of iodide of potash 
can be continued almost indefinitely, often with great relief to 
the patient. 

Next in importance to iodide of potash is arsenic, given 
either in the form of Fowler's solution, beginning with five 
drops, three times a day, in water, and increasing the dose until 
fifteen drops, three times a day, are taken; or in the form of 
arsenious acid, sodium arseniate or sodium cacodylate (see page 
74). Arsenic, too, should be given interruptedly, the patient tak- 
ing the maximum dose for three or four weeks and then grad- 
ually reducing it, only to increase it again when the lowest dose 
is reached. Iodide of potash is the best remedy when there is 
much bronchitis, emphysema or arterio-sclerosis, or if there are 
manifestations of goutiness, whereas arsenic seems to yield bet- 
ter results in young, neurotic subjects without bronchitis or 
emphysema. 

Atropine is another useful remedy, provided the iodide of 
potash and the arsenic do not exercise the desired effect; it 
should be given in rather large doses, i. e., one-one-hundred-and- 
fiftieth to one-one-hundredth of a grain, two or three times a. 
day for a considerable period of time, care being always taken 
that symptoms of atropine poisoning do not make their appear- 



BRONCHIAL ASTHMA 289 

ance. Atropine presumably acts by paralyzing the vagus ter- 
minations, thus reducing the spasm of the bronchial muscula- 
ture and suppressing the bronchial secretion. 

For the treatment of the acute attack a great many remedies Treatment of 
have been recommended. It is necessary in bronchial asthma, ta ck acu e a " 
owing to its manifold origin and the varying idiosyncrasies of 
many sufferers from this disease, to try a great many different 
remedies before finally one is discovered that seems to be spe- 
cifically active in the particular individual. The most generally 
useful remedy to abort an attack is probably chloroform, which Chloroform 
may either be administered in small whiffs or given internally 
as chloroform water in the dose of one to two teaspoon fuls, or 
as spirits of chloroform in twenty to sixty drops. If the par- 
oxysm is not promptly checked by chloroform, then morphine 
should be given hypodermically in one-eighth grain doses, com- Morphine 
bined with a one-two-hundredth grain of atropine and two to 
five drops of a ten per cent, solution of cocaine hydrochlorate ; Cocaine 
this dose to be repeated two or three times if necessary. As it 
is not practicable nor altogether safe to leave the hypodermic in 
the hands of the patient, this treatment should be reserved for 
use by the physician if he is called in early to a case of severe 
bronchial asthma. The patients may have on hand for internal 
use a solution of chloral Irydrate, which is best given in combina- Chloral 
tion with large doses of bromide of potash well diluted with some 
simple syrup and water. The following prescription I have Bromides 
found useful for stopping attacks of bronchial asthma : 

i* 

Chloral hydrate, 4 gm. 

Potassium bromide, 12 ec. 

Simple syrup, 32 cc. 

Water, 96 ec. 
M. 

S. A dessertspoonful every hour until relieved, 

or until four are taken. 

Chloral hydrate should, of course, never be prescribed unless 
the heart is altogether intact. A useful substitute for chloral 
hydrate in such cases is chloralamid (see page 36), which may Chloralamid 
be given in doses of ten to thirty grains (0.65 to 2 gm.) two or 
three times in succession at intervals of one hour. 

Very popular are asthma cigarettes made of the leaves of Asthma cig- 
stramonium, belladonna, hyoscyamus or lobelia, usually mixed 
with potassium nitrate or smoked through paper that has been 
soaked in nitrate of potash. Trousseau recommends the follow- 
ing cigarette: 



290 



CAPILLARY BRONCHITIS BRONCHO-PNEUMONIA 



V 



Cannabis 
indica 



Inhalations of 
potassium ni- 
trate, ammonia 
vapors, to- 
bacco smoke 



Steam 



Leaves of belladonna, 
Leaves of hyoscyamus, 
Leaves of stramonium, 
Phellandrium aquat, 



0.36 
0.18 

0.80 
0.06 



The ribs are removed and the leaves cleansed, a trace of ex- 
tract of opium added and the mixture rolled up in paper treated 
with laurel water and dried. The mixture of these leaves may 
also be cut up fine and ignited on a plate and the fumes inhaled. 

Cannabis indica is also used in the form of cigarettes and 
very good results are claimed from its use. The following mix- 
ture is particularly recommended by Ortner: 



? 



Stramonium leaves, 
Potassium nitrate, of each, 
Belladonna leaves, 
Herb, cannabis indica, of each, 



2 

10 



The mixture may be used either in cigarettes or it may be 
mixed with nitre, ignited on a plate and the fumes inhaled. 

In order to be effective the smoke from these cigarettes must 
always be inhaled. It is impossible to predict in advance 
whether or not they will help, but it is certainly worth while 
to try them in every case. Other remedies that are used for 
inhalation are nitrate of potash, which may, in a simple manner, 
be vaporized on a hot spoon. Ammonia vapors also occasionally 
relieve. Strong ammonia water is poured into a glass and the 
patient after plugging his nostrils with cotton inhales the whiffs 
of ammonia that are carried to his mouth by fanning across the 
top of the vessel. It is finally worthy of mention that some pa- 
tients obtain marked relief from smoking tobacco. 

It is always good practice during the attack to develop steam 
in the room. Sometimes relief is obtained if the patients re- 
peatedly dip their hands or feet, or both, into hot water. 
Whether this is a reflex vaso-motor effect or pure suggestion is 
hard to determine; yet as the measure can do no harm, often 
does good, and is very simple, it should be advised. 



CAPILLARY BRONCHITIS— BRONCHO-PNEUMONIA. 

Catarrh of the smaller bronchioles (bronchitis profunda, 
bronchiolitis capillaris), especially in children and old people, 
frequently extends to the infundibula and ultimately involves 



CAPILLARY BRONCHITIS BRONCHO-PNEUMONIA 291 

the lobules of the lungs. From a clinical point of view, there- 
fore, it is practical to consider capillary bronchitis and broncho- 
pneumonia together. 

Owing to the occlusion of numerous air channels and the Involvement 
° . of the right 

narrowing of the bronchial lumen in either disease, the aeration heart 

of the lungs becomes deficient so that an excessive amount of 
labor is thrown both upon the right heart and upon the muscles 
of respiration. In most cases fever sets in that in its turn ex- 
ercises a deleterious effect upon the heart muscle. Most cases, 
therefore, as will readily be understood, die not from the bron- 
chial and pulmonary inflammation directly, but rather from 
embarrassment and failure of the right heart. One of the main 
objects of treatment, consequently, should be to support the 
heart, relieve the respiratory muscles of their excessive labor 
and reduce the temperature. Hydrotherapy 

Here lukewarm baths (90° to 96° F.) gradually reduced to 
75° or 60°, or followed by cold sponging, are the sovereign rem- 
edy. The explanation of their action is the following: By 
immersion in water that is somewhat below the normal body 

temperature a preliminary contraction of the cutaneous vessels Lukewarm 

baths 
is produced, especially in febrile cases; this is followed by a 

reactive dilatation of these vessels which can be markedly en- 
forced by rubbing tiie patient while he is in the bath. The pri- 
mary shock and the sudden contraction of the skin vessels causes 
reflex stimulation of the heart and of the respiratory centres as 
manifested by a rise of the blood pressure and a few deep in- 
spirations. The passive hyperemia of the skin which follows, in 
its turn depletes the bronchial mucosa, relieves the heart, re- 
duces the blood pressure and quiets respiration. The effects of 
the primary shock are very transitory, whereas the reaction per- 
sists for a long time. A second reaction can be secured if the 
patient upon leaving the bath is rapidly sponged with cold water 
of room temperature and is at once put to bed between warmed 
linen sheets and given the benefit of an energetic dry surface 
massage. The duration of the bath should not exceed ten to 
fifteen minutes and two or three such baths may be given during 
the day. This bath treatment is particularly useful in cases 
of capillary bronchitis affecting strong individuals without pul- 
monary involvement and without high fever. In all cases it is 
good practice to give a teaspoonful or two of brandy before the 
bath. If myocardial or arterio-sclerotic changes are present 
such cool baths should, of course, never be given. 

Instead of cool baths the cold pack may be applied as fol- ° pac 
lows : A linen sheet is wrung out of water of from 50° to 65° 
F. and the patient quickly wrapped up in the sheet and covered 



292 CAPILLARY BRONCHITIS BRONCHO-PNEUMONIA 

with a woolen blanket. Here, too, there is a preliminary shock, 
promptly followed by the desired reaction. It is best to cover 
only portions of the patient 's body at a time, applying the sheet 
once to the thorax, then to the abdomen and then to the legs. 
In very nervous subjects and in cases suffering from much 
dyspnea, I have made it a rule always to leave the arms free 
when administering a wet pack, for wrapping the sheet around 
the arms causes a sense of restraint and oppression that excites 
and worries the patients and reacts unfavorably upon the heart's 
action and the blood pressure — conditions which should be 
avoided. The cold packs should be repeated at short intervals 
until the temperature is lowered several degrees. As a rule, 
after the first pack the temperature at first falls quickly, but 
rises again as quickly, i. e., within a few minutes, so that it 
usually requires three or four applications of the wet sheet to 
keep the temperature permanently down. 

Hot bath In some forms of capillary bronchitis there is no fever, the 

patients even develop sub-normal temperatures with cyanosis 
and cold hands and feet; here cold hydrotherapeutic measures 
are altogether out of place and the hot pack or the hot bath 
should be given instead. Contra-indications to the use of hot 
hydrotherapeutic measures are myocardial changes and arterio- 

Hot pack sclerosis. In giving the hot pack the sheet is wrung out of 

water of 100° to 105° F. and the patient speedily wrapped into 
it and covered as above; or the patient may be placed into a 
bath of 100° F. for ten or fifteen minutes. In either case an 
ice bag or cold cloths should be applied to the head. As soon 
as the hot cloth is removed or the patient leaves the hot water, 
the skin should be energetically rubbed with a warm rough 
towel and the patient placed to bed and covered with linen or 
cotton bed-clothing. 

The good effects of the hot bath must be attributed to the 
passive hyperemia of the skin that sets in promptly, for the 
dilatation of the superficial capillaries that is produced is prac- 
tically synonymous with bleeding the patient into his own ves- 
sels ; the fall in the blood pressure that resuljbs herefrom greatly 
relieves the heart without depressing it. Here, too, as in the 
case of cool bathing, the first contact with the hot water stimu- 
lates deep respirations and aids expectoration. The prolonged 
exposure to heat, besides, exercises a very desirable sedative in- 
fluence on the nervous system, most patients promptly falling 
asleep after such bath. The temperature occasionally rises 
slightly while the patient is immersed in the hot water, but in 
febrile cases it generally drops 2 or 3 degrees as soon as the 
patient is back in bed. 



CAPILLARY BRONCHITIS BRONCHO-PNEUMONIA 293 

The air in the room should always be kept moist. This is Moistening 
best done by hanging sheets wrung out of hot water in the the air 
room, or by developing steam from a kettle or pan. In children 
the bronchitis tent described elsewhere (page 280) may be used 
and steam developed underneath it. 

Cases that set in with high fever, and all cases of capillary Rest in bed 
bronchitis developing in children and old people, should be 
kept in bed, preferably in a semi-recumbent position; the pa- 
tients should be ordered to frequently change their position so ^ ha .^f e of 
as to prevent hypostatic congestion of the lungs. Little children 
with capillary bronchitis should be frequently lifted out of bed 
and carried about. 

The diet should be very strengthening but not bulky. No I)iet 
articles of food should be given that can dilate the stomach or 
produce gaseous distension of the stomach or bowels, as, other- 
wise, the heart's action may be mechanically interfered with 
and full excursions of the diaphragm downward prevented, so 
that coughing and expectoration would be rendered difficult. 
The diet should, therefore, be largely albuminous, consisting of 
scraped meats, broth, milk, eggs, with a little fresh fruit and 
fresh vegetables and a minimum of starchy foods and fats. 
Little food or drink should be taken at one time, the patient 
preferably eating small meals at frequent intervals. A little 
alcohol in the form of dilute claret, Rhine wine or whisky 
throughout the disease can do no harm ; the alcohol acting bene- 
ficially both on account of its food value and on account of its 
general stimulating and supporting effect upon the heart. If 
symptoms of heart weakness appear, alcohol is by far the best 
stimulant in this disease. 

The bowels should be kept open throughout the course of Regulation of 

the bowel 
the disease. Constipation and intestinal flatulence or meteorism function 

are to be carefully avoided in order not to interfere with the 
movements of the diaphragm. In the beginning free catharsis 
should be promoted by a tablespoonful of castor oil, or by calo- 
mel best given in one-tenth grain doses repeated ten times 
and followed by a tablespoonful of magnesium sulphate in 
water. Later a mild saline laxative or wine of cascara may be 
given in doses sufficiently large to produce one or two free 
evacuations of the bowels every day. 

The medicamentous treatment of the bronchitis per se does Medicamentous 
not differ very materially from that advised in other forms of 
acute bronchitis (see page 281). If the disease sets in suddenly 
with high fever, drop doses of the tincture of aconite every two Aconite 
or three hours should be given. Narcotics should be used very 



294 



PULMONARY EMPHYSEMA 



Stimulating 
expectorants 

Emetic expec- 
torants 



Heart tonics 



Narcotics sparingly, as it is self-evidently always dangerous to suppress 

the cough and stop the expectoration. If the cough is very dis- 
tressing, if it is wearing the patient out, preventing sleep or 
straining the heart, as manifested by an irregular heart action 
after each coughing effort, then a five-grain dose of Dover's 
powder, or one-eighth grain of morphine with one-two-hun- 
dredth grain of atropine, or a one-fourth grain of codeine, may 
be administered several times a day. Stimulating expectorants 
as strychnine, senega or ammonium chloride, and small doses of 
the emetic expectorants, ipecac, tartar emetic, apomorphine, 
may be given with the reservations and precautions outlined in 
the Chapter on Valvular Lesions (see page 38) and the Section 
on Acute Bronchitis (page 282). 

As soon as alarming signs of heart weakness appear, heart 
tonics must be given (see page 32). I have made it a practice to 
give very small quantities of digitalis or strophanthus, i. e., two 
or three drops of the tincture several times a day from the very 
onset of the disease. In this way the heart's action is rendered 
more regular, while, at the some time, no over-stimulation is 
produced. I have never seen any ill-effects from this practice. 
If small doses are given larger doses always remain available for 
emergencies. If signs of heart failure appear suddenly (and if 
the case is carefully watched from the beginning and treated 
with small doses of heart tonics this failure is not apt to appear 
unexpectedly), camphor, ether, ammonia must be given hypo- 

Analeptics dermically (see page 32) and the patient sponged or douched 

with very cold and very hot water alternately. On rare occa- 

Oxygen sions it may become necessary to resort to inhalations of oxygen, 

combined with the use of strychnia in one-twentieth to one- 
fortieth grain doses, given hypodermically in order to overcome 
cyanosis, excessive dyspnea and lividity. 

The treatment of the convalescent stage is the same as in 
any other form of bronchitis. 



Limitations of 
treatment 



II. DISEASES OF THE LUNGS. 

PULMONARY EMPHYSEMA. 

On account of the mechanical and destructive character of 
the lesion in pulmonary emphysema a cure of this disorder is 
manifestly out of the question. We are dealing with a rarefac- 
tion of the intralobular septa either throughout the lung or in 
certain circumscribed regions (as in compensatory or traumatic 
emphysema) with atrophy of the alveolar walls, obliteration of 
capillaries and loss of elastic tissue and, in many cases, anatomic 
rigidity of the chest wall with ossification of costal cartilages. 



PULMONARY EMPHYSEMA 295 

When one considers further that in many cases of em- Hereditary 
physema, especially when occurring in young people (with or element 
without the co-operation of factors like over-exertion and vio- 
lent respiratory efforts incident to various occupations), a dis- 
tinctly hereditary element, manifesting itself by abnormally high 
intra-pulmonic blood pressure and congenital weakness of the 
alveolar walls must be included in the question, then it becomes 
clear that even prophylactic treatment directed towards check- 
ing the progress of emphysematous changes when they first 
make their appearance is generally a futile task. 

For all these reasons the treatment of emphysema is of Treatment 
necessity largely symptomatic. Our efforts must be directed t ^® t f c ^^-'P" 
chiefly towards counteracting the bronchitis that complicates 
and aggravates most cases of the disease; then towards prevent- 
ing or correcting the dilatation and hypertrophy, especially of 
the right heart, that generally precede or follow emphysema ; and 
towards relieving the signs of venous stasis about various organs 
that develop consecutively to the cardiac insufficiency. Finally 
the asthmatic seizures and the attacks of dyspnea that render 
the existence of advanced cases of emphysema so hard to bear 
must be energetically treated and if possible relieved. 

In undertaking to treat the bronchial catarrh in anj case The cornpli- 
of emphysema of the lungs it is very important, as a preliminary chiS 8 cat' r 1 li 
step, to determine whether the bronchial catarrh preceded the 
emphysema or whether it developed consecutively to emphyse- 
matous rigidity of the lung. This point can usually be deter- 
mined with some degree of accuracy from the history. 

If the bronchitis preceded the emphysema then it is pre- Expectorants 
sumably of the simple catarrhal variety, and here the various 
cough remedies, sedatives, expectorants, etc., that have been 
described in full in the Section on Chronic Bronchitis (page 
284) have their field of usefulness. 

If the bronchitis developed after the emphysema, then it Cardiac tonics 
is generally due to venous hyperemia of the bronchial mucosa 
produced by the impeded pulmonary circulation and the weak 
action of the right heart that so commonly supervenes in pul- 
monary emphysema. If a careful examination of the heart re- 
veals dilatation of the right half and marked accentuation of 
the second pulmonary sound and if, at the same time, evidence 
of venous stasis, due to cardiac insufficiency, is discovered in 
other regions of the body, then venous stasis can be charged 
with producing the bronchial catarrh, and the treatment should 
be largely cardio-tonic, as described in the section on Valvular 
Diseases in the stage of failing compensation. 

Unfortunately the exact determination of the heart bounda- 



296 



PULMCNARY EMPHYSEMA 



Significance of 
bloody sputum 



Catarrhal 
asthma 



Dyspnea 



Climate and 
resorts 



ries is frequently a very difficult matter in emphysema because 
the superficial heart dullness is commonly obliterated in emphy- 
sema of the anterior margins of the lungs, and because deep 
percussion does not yield very positive information in advanced 
degrees of emphysema. The presence of a little blood in the 
sputum may aid in the differential diagnosis between hyperemic 
catarrh of the bronchi, due to venous stasis, and simple bron- 
chitis, slight degrees of hemoptysis speaking for hyperemia of 
the bronchi. 

A therapeutic test, finally, with heart tonics may aid in 
the decision ; for venous stasis in the bronchi, i. e., hyperemic 
catarrh, yields readily to the judicious use of these tonics, 
whereas catarrhal bronchitis is in no way influenced by cardio- 
tonic medication. 

There is still another variety of bronchial catarrh in em- 
physema that assumes the characteristics of catarrhal asthma. 
The dyspnea is paroxysmal and spasmodic and the sputum in 
many cases contains eosinophile cells. Here, too, the catarrhal 
asthma may have preceded the emphysema or it may have fol- 
lowed it, the former being the more common event. The treat- 
ment of this variety of bronchial catarrh must be carried out 
as described in full in the Section on Bronchial Asthma. 

It will usually be found that if the bronchitis, soil., the 
cough, expectoration and the asthmatic paroxysms, are held in 
check the patients notwithstanding their emphysema will feel 
relatively comfortable, in fact, rarely suffer from their em- 
physema per se unless the latter is so far advanced as to ma- 
terially reduce the breathing surface of the lung and to cause 
marked insufficiency of the right heart with all that that en- 
tails. Hence it is a matter of greatest importance to determine 
the exact cause of the bronchial trouble and to attack it energet- 
ically. 

The dyspnea that emphysematous patients suffer from calls 
for the same careful analysis as the bronchial catarrh. It may 
be due either to the emphysema itself, i. e., it may result 
from the reduction of the breathing surface of the lung, or it 
may be paroxysmal in character, i. e., an asthmatic dyspnea, or 
it may be due to cardiac insufficiency. In the latter case appro- 
priate cardio-tonic treatment is usually effective; in asthmatic 
dyspnea the treatment is the same as given in the Section on 
Bronchial Asthma. 

In view of the chronic character of emphysema the choice 
of a resort or a climate and of the proper altitude is exceed- 
ingly important. Here, as in the selection of all the other 



PULMONARY EMPHYSEMA 297 

remedial measures that are to be employed, the exact causes 
that determine the complications, chiefly the bronchitis and 
the dj^spnea, must be considered and advice rendered accord- 
ingly. 

Thus in the selection of an altitude everything will depend Altitude 
upon the condition of the heart, the severity of the bronchial 
catarrh and the degree of emphysematous dilatation of the 
lung. 

If the emphysema predominates and the bronchial catarrh Moderate al- 
is relatively slight and the cardiac insufficiency not far ad- tltudes 
vanced, then a moderately high altitude should be selected, for 
these patients complain chiefly of difficulty in getting rid of 
the air, that is, of expiratory dyspnea ; so that the low barometric 
pressure at an altitude and the rarefied air render expiration 
•easier and hence help the patient. Incidentally slight degrees 
of bronchial catarrh are not unfavorably influenced by an alti- 
tude. 

If, on the other hand, the catarrhal condition of the bronchi Southern low 
predominates so that there is abundant irritating secretion and climates 
much cough with resulting strain upon the heart, then these 
patients should be advised against seeking high altitudes and 
should live in a Southern climate at a low barometric pressure 
with the minimum of temperature changes, a maximum of clear, 
sunshiny days and little humidity in the air. The latter require- 
ments can frequently only be met in semi-tropical arid regions; 
here however the dust and alkali in the air usually constitute 
a serious irritant to the bronchial mucosa and produce violent 
coughing efforts — therefore the climatic advantages are often 
neutralized in this way, so that emphysematous patients should 
be sent by preference to moist: warm, rather than to dry, warm Sea sn <> re and 
climates. For such cases the seashore in Southern regions, or 
an ocean voyage through Southern seas, is of signal benefit. 

Patients who cannot seek a proper climate occasionally derive Pneumatic 
benefit from the use of pneumatic chambers at home and in re- chamber 
sorts located not too far from home. A great many different 
kinds of apparatus have been constructed by means of which 
the patient breathes under pressure; all of them improving 
the bronchial catarrh of emphysema provided it is due to hyper- 
emia of the bronchial mucosa. Symptomatically, too, breathing 
compressed air helps many cases of emphysema; the exact 
scientific explanation of this clinical fact is still forthcoming. 

In choosing a resort for an emphysematous case the charac- Laxative 
ter of the waters may be advantageously considered in addition waters 
to the altitude and climate and the facilities for breathing com- 
pressed air. Resorts furnishing laxative water should be given 



298 



PULMONARY EMPHYSEMA 



Diet 



Little albumen 



No large meal 



Reduction of 
obesity 



Venesection 



the preference for by the judicious use of saline laxatives ab- 
dominal plethora is corrected and hence the right heart re- 
lieved of much labor and breathing thus facilitated. On the 
same principle catharsis by saline laxatives should be promoted 
at home. 

The diet should be selected with the object in view chiefly 
of preventing abdominal plethora and over-loading or disten- 
sion of the stomach. Consequently the diet should not contain 
too much albuminous pabulum, for the latter produces engorge- 
ment of the mesenteric veins during digestion, i. e., abdominal 
plethora, more than other food. The use of aerated beverages 
and of fermenting foods chiefly of the starchy variety, should 
be interdicted. If necessary anti-fermentative remedies (see 
Meteorism) , may be given from time to time to prevent flatu- 
lency and distention of the stomach and bowel. In cases with 
a tendency to dyspnea large meals should never be allowed; 
the patient should be instructed to eat small meals at fre- 
quent intervals. All these dietetic rules are intended to pre- 
vent pressure upon the diaphragm from below by a distended 
stomach or bloated bowel and hence interference with free res- 
piratory excursions. 

If the patient with emphysema is obese, then a reduction cure- 
is an exceedingly useful element in the treatment; for the 
presence of large quantities of intra-abdominal fat interferes, 
with the respiratory movements of the diaphragm downward and 
hence increases the dyspnea, an effect that is enforced by the 
weight of large fat masses upon the thorax. Obese patients,, 
moreover, as a rule suffer from abdominal plethora, constipa- 
tion, flatulency, all factors that should be counteracted in em- 
physematous dyspnea. Finally, the heart, as is well known, is- 
particularly over-strained in advanced degrees of obesity. This, 
is due in part to the presence of fat masses around the organ 
and infiltration of the heart muscle by fat, or to fatty degenera- 
tion of the heart muscle; in part to the great resistance offered 
to the flow of blood by the fine network of capillaries that forms 
in new adipose tissue ; and to many other causes that have been 
discussed in full in the Section on Obesity on page 148. Some of 
the most gratifying results are obtained precisely in obese em- 
physema cases suffering from much dypsnea, bronchitis and 
symptoms of stasis in various organs as soon as the bulk of the- 
patient is reduced by a carefully carried out cure. For the 
choice of method and the technique of the latter I refer to the 
Section on Obesity. 

Occasionally a patient with advanced emphysema suddenly 
develops quite alarming degrees of dyspnea and cyanosis that 



PULMONARY EDEMA 299 

endanger his life. In such cases without regard to what the 
exact pathogenesis of these phenomena may be in the individual 
case (and time will rarely be given to make a careful analysis 
of all the contributing factors) bleeding is the sovereign remedy. 
From two to three hundred cc. of blood should be removed at Oxygen in- 
once from the median basilic vein, as described on page 37 At 
the same time inhalations of oxygen may be given; two or 
three gallons of oxygen being administered every two or three 
hours. If the excitement is great and the patient very restless, 
then an hypodermic injection of an eighth of a grain of mor- Morphine 
phine with a two-hundredth of atropine frequently furnishes 
prompt relief. While these measures are being carried out the 
heart should be supported by the hypodermic administration of Analeptics 
analeptics, camphor, ether, ammonia, strychnia, given as de- 
scribed in detail in the Section on Valvular Diseases of the 
Heart in the stage of failing compensation (see page 32). 



PULMONARY EDEMA. 

There is an inflammatory pulmonary edema due to local pro- Collateral pul- 
cesses and occurring in the neighborhood of acutely inflamed onar y e ema 
areas, infarcts, tumors, etc., of the lungs, mediastinum ana pleu- 
ral cavities. This so-called collateral pulmonary edema is due 
either to local injury produced in the vessel walls of a given 
vicinity by bacterial toxins, or it may be due to plugging of 
blood-channels and lymph spaces, or to mechanical compres- 
sion of the latter in circumscribed areas of the lung. This 
local pressure or plugging, with or without degeneration of the 
vessel walls by toxins permits diapedesis of serum and probably 
also of corpuscles into the air cells and the alveolar tissues of cer- 
tain circumscribed regions of the lung and, in this way. pro- 
duces localized pulmonary edema. 

This variety is rarely amenable to treatment other than that 
directed towards the underlying cause. In fact, the edematous 
area is often so small as to cause little discomfort and produce 
few symptoms. If large areas of the lungs become edematous 
from this source, then the symptomatic treatment is the same 
as that of any other form of acute pulmonary edema. 

Edema due to paralysis of the musculature of the pulmonary An^io-neu- 
arteries may be a part phenomenon of hysteria (angio-neurotic rotlc edenla 
edema) or it may occur in the course of chronic intoxications 
as, e. g., in uremia, acute alcohol poisoning, lead-poisoning, Toxic edema 
iodide-poisoning, etc. 

The most common form of pulmonary edema, however, is 



300 



PULMONARY EDEMA 



Edema due to 
stasis 



Pulmonary 
edema usually 
due to several 
factors 



Condition of 
the heart im- 
portant 



Cardiac tonics 



Catharsis 

Diuresis 

Diaphoresis 

Cupping 1 



Avoidance of 
iodids and 
bromids 



that produced by stasis in the pulmonary veins. This is an edema 
of the lungs that accompanies general disorders involving the 
competency of the heart, hence it often constitutes a terminal 
phenomenon in a variety of infectious and chronic cachectic 
disorders; it also occurs in valvular diseases of the heart and 
in cardiac disorders of manifold origin, fatty heart and myo- 
carditis. 

In most cases of pulmonary edema several of the above fac- 
tors are operative; thus, for instance, in uremic edema occur- 
ring in cardio-renal disease there is at the same time chronic 
intoxication from renal insufficiency, and a weakened heart 
and weakened blood vessels. In pulmonary edema occurring in 
infectious diseases, as typhoid, measles, influenza, pneumonia, 
etc., there is a general bacterial toxemia and often, at the same 
time, myocardial degeneration as a result of the infection. In 
pulmonary edema occurring in the course of anemia and cachec- 
tic states there is usually injury to the structure of the blood 
vessel walls from malnutrition and, at the same time, a heart 
with a weakened myocardium and self-ovidently with a tend- 
ency to dilatation and insufficiency. 

It will be seen, therefore, that in almost all cases of chronic 
pulmonary edema the condition of the heart must, above all 
things, be seriously taken into consideration, hence the treatment 
differs somewhat according to the condition of the heart. 

One can for therapeutic purposes distinguish between cases 
of chronic pulmonary edema in which the heart's action is good 
and the myocardium apparently intact, and cases in which 
the heart's action is weak and in which evidences of myocar- 
ditis, dilatation, fatty degeneration, etc., are apparent. 

The latter variety of cases is by far the most common of 
the two. Here the judicious use of cardiac tonics and of all 
the other hygienic, dietetic and hydrotherapeutic measures that 
have been described in full in the Section on Valvular Diseases 
of the Heart in the state of broken compensation must be em- 
ployed. Here, too, active catharsis and the stimulation of diure- 
sis and diaphoresis, with all the precautions and reservations 
that have been discussed at length in the above section, have a 
useful field of application. Dry cupping over the chest (see 
page 39) is a useful adjuvant to the treatment, especially in 
those peculiar cases of cardio-renal edema of the lung in which 
the edematous effusion seems to occupy circumscribed regions 
of the lung only. 

In all cases of chronic pulmonary edema particular care 
should also be exercised to avoid the administration of certain 
drugs that can produce hyperemia and congestion of the bronchi, 



PULMONARY EDEMA 301 

notably iodids and bromids. This warning is appropriate be- 
cause in many cases of chronic pulmonary edema insomnia, due 
to the difficulty of breathing and possibly to circulatory disturb- 
ances of the brain that result from the cardiac insufficiency, is 
a very distressing symptom. Here the temptation is always given 
to administer bromids. On the other hand many cases of cardio- 
renal disease develop on the basis of a syphilis, so that a course 
of antiluetic medication with large doses of iodids might. seem 
indicated. 

Acute edema of the lungs developing as an exacerbation of Acute edema 
chronic edema or occurring suddenly and independently, im- 
material what its origin, calls for rapid interference, for this 
disorder always constitutes an emergency that threatens the life 
of the patient. 

The best remedy in any case is atropine or its congeners, Atropine 

hyoscine (scopolamine). These remedies should be given hypo- y° scine 
,.,,., , ,.. n P . . Scopolamine 

dermically in large doses, that is, m doses or one-sixtieth to 

one- thirtieth of a grain (1 to 2 mg.) repeated two or three 
times, or oftener at intervals of one hour. To give smaller doses 
is, in my experience, a waste of time. The after-effects of the 
large doses of atropine or hyoscine are disagreeable, but one is 
dealing with a life and death question in which unpleasant 
sensations affecting the patient should not be considered. The 
action of atropine and hyoscine is to stimulate both the respira- 
tory centers and, at the same time, the vaso-constrictors ; in this 
way, in all probability, counteracting the mechanical dilatation 
of the vessel walls and rendering them less permeable to blood 
serum. In acute edema occurring in the course of chronic 
cachectic diseases and in disorders accompanied by malnutrition 
and degeneration of blood vessel walls no ready response to vaso- 
constrictor influences will be obtained; but cases advanced to 
this point are almost invariably fatal and as no harm can be 
done by giving atropine in large doses a trial, one need not hesi- 
tate to begin the emergency treatment, even in such cases, with 
large doses of atropine or hyoscine. 

Second in importance to atropine is ergot. This drug also Ergot 
is given on account of its power to cause constriction of blood 
vessels in certain areas of the body. Ergot does not produce 
general vaso-constriction, otherwise it would raise the general 
blood pressure much more than it does. It causes constriction 
merely of the blood vessels in certain areas of the body ; we know 
positively that it exercises this effect about the female adnexa, 
whether it exercises the same effect upon the pulmonary blood 
vessels we do not know positively, but some experimental evi- 
dence seems to indicate that it does. Empirically and clinically 



302 



PULMONARY EDEMA 



Action of ergot 



Mode of ad- 
ministration 



we know, at all events, that it raises the blood pressure in the 
pulmonary circulation and hence we are justified in concluding 
that it also exercises a local vaso-constrictor effect; for this rea- 
son the remedy is useful in pulmonary edema, and for the same 
reason it is so dangerous in hemoptysis (see page 310) ; for if 
there is rupture or erosion of blood vessels within the pulmonary 
area the beneficial effects that might accrue from the vaso- 
constriction are more than neutralized by the rise in blood pres- 
sure that is at the same time produced. 

If given in pulmonary edema it should.be given either in the 
form of the Injectia Ergota Hypodermica in the dose of three 
to twenty drops, or by mouth as the solid extract of ergot in 
doses of three to sixteen grains (0.2 to 1 gm.). It can, to advant- 
age, be combined with atropine and the following combination 
I have found useful and safe : 



? 



Atropine, 1-50 gr. (0.0013 gm.) 

Extract of ergot, 10 gr. (0.6 gm.) 

M. Sig. One capsule every hour until relieved 
or until four are taken. 



Cacodylate of 
soda 



Analeptics 



Still another remedy that may be used as an emergency meas- 
ure in pulmonary edema is cacodylate of soda. This prepara- 
tion of arsenic should be given in large doses in order to be 
effective. It exercises a most remarkable influence upon exu- 
dates and edematous effusions without, to my knowledge, pos- 
sessing any disagreeable after-effects. It is perfectly safe to 
give sodium cacodylate hypodermically in one grain doses, in 
watery solution, every three or four hours, for four or five doses. 
A convenient way to administer the remedy is to have a solution 
of fifteen grains of cacodylate of soda to the ounce of water 
made and to inject a Pravaz needle full subcutaneously or in- 
tramuscularly every three or four hours. When one consid- 
ers that one grain of cacodylate of soda contains as much arsenic 
approximately as three-fifths of a grain of arsenious acid, the 
absence of symptoms of arsenic poisoning after the administra- 
tion of this drug is very remarkable. 

If there is much cyanosis in acute edema with other evi- 
dence of embarrassment of the right heart, then active cardio- 
tonic medication becomes necessary. Here the character of the 
pulse, the size of the heart, the strength of the apex beat and 
its reaction must all determine the dosage of the various analep- 
tics and cardio-tonics that are to be administered. The same 



PULMONARY INFARCT, ABSCESS AND GANGRENE 302 

principles should govern us here as in the treatment of cardiac 
stasis due to decompensated valvular lesions. Ether, ammonia, 
camphor, camphor in ether, camphor in oil, champagne and, in 
less acute cases, digitalis, strophanthus, caffein, all have their 
application (see page 32). 

Venesection may be practised in extreme cases and very Venesection 
marked relief is frequently obtained from the withdrawal of two 
or three hundred cc. of blood. It is always safe and good treat- 
ment, if none of the above emergency medicines are immediately 
available, or if they do not act very promptly, to bleed the patient Leeches to 
as a preliminary measure. In the same sense the application of 
leeches to the anus, i. e., bleeding from the hemorrhoidal veins 
occasionally helps (see page 40). 

In advanced cases of cardiac incompetency with venous Paracentesis 
stasis in the portal area and abdominal ascites, paracentesis of i n p0 rtal 
the abdomen and withdrawal of some of the ascitic fluid fre- stas is with 
quently exercises a very beneficial effect upon the pulmonary edema 
edema. This effect must be attributed to the relief of pressure 
produced within the abdomen which enables the veins of the por- 
tal area to expand more readily and consequently to harbor more 
blood within their lumen. Abdominal puncture in these cases 
is, therefore, in a sense, bleeding the patient into his own blood 
vessels. 



PULMONARY INFARCT, ABSCESS AND GANGRENE. 

In view of the mechanical character of the lesion in pulmon- 
ary infarct the treatment is largely symptomatic. 

Prophylaxis is in a sense possible ; for given on the one hand Prophylaxis 
a phlebitic process about one of the extremities, the brain sinus, 
uterus, the hemorrhoidal veins, about recent fractures, or on the 
other hand, a weak right heart with endocardial disease, or both, 
and the possibility of embolus formation and pulmonary infarc- 
tion must always be remembered. Hence the existence of any 
of the above named conditions should put us on the alert for 
pulmonary infarct and the attempt should be made to prevent 
its development. 

The principles that should govern this prophylactic treat- Principles of 
ment are the following: We know from experience that there is P ro P n y laxis 
less probability of embolus formation in the marantic variety of 
phlebitic thrombi that develop as a late phenomenon in chronic 
cachectic disease, cancer, severe anemias, phthisis, etc., 
than in thrombosis due to acute phlebitic processes. This is 
owing to the fact that marantic thrombi develop slowly and are 
consequently better organized, i. e., more solid and more adherent 



304 



PULMONARY INFARCT, ABSCESS AND GANGRENE 



Rest and im- 
mobolization 
in acute 
phlebitis 



Danger of mas- 
sage and in- 
unctions in 
phlebitis 



Treatment of 
sudden infarc- 
tion 

Artificial res- 
piration 

Oxygen 

Hot compresses 
Analeptics 



Morphine 



to the vessel walls than thrombi that develop rapidly as the re- 
sult of acute phlebitis; and also to the fact that sufferers from 
marantic thrombosis are usually very weak and of their own 
inclination remain quiet, while patients with acute phlebitis are 
strong, apt to be restless and to move about a good deal, hence 
favoring the breaking off of emboli from the thrombus. 

In acute phlebitic disease consequently every effort should be 
made to favor- slow development of the thrombus and to keep* 
the patient quiet, in this way rendering the breaking off of frag- 
ments of the thrombus and hence embolization and infarction in 
remote regions of the body less probable. 

Every patient with phlebitis should therefore be put at rest 
in a recumbent posture and should be warned against perform- 
ing any sudden movement. If the phlebitic process is going on 
in some extremity of the body then the latter should be immobil- 
ized with loose bandages or splints and kept perfectly quiet in a 
horizontal position. Massage of the affected limb should not be 
given nor inunctions, that are so popular in phlebitis, be admin- 
istered. Rest of the body and of the affected extremity should 
be maintained until all the sequelae of blood vessel occlusion have 
disappeared, that is, until the extremity has regained its natural 
red color and temperature and size. As long as the limb is swol- 
len, pale, cool and edematous there is danger of embolization. 
In phlebitic processes, involving the pelvic or the hemorrhoidal 
vessels, straining at stool, violent coughing efforts and hiccough 
should be avoided as much as possible. 

If in spite of these precautions, that cannot unfortunately 
be carried out successfully in every case, the patient suddenly 
experiences a pain in the chest, begins to cough violently, becomes 
dyspneic, possibly spits some blood and faints, then infarction 
of the pulmonary vessel with extravasation of blood into the pul- 
monary air cells and the interstitial tissues of some region of the 
lung may be suspected. 

The treatment of this syndrome is the following : If the pa- 
tient is in syncope, as a result of the infarction, he should be 
placed in a horizontal position. If there is much dyspnea arti- 
ficial respiration should be practised and oxygen inhalations 
given. At the same time hot compresses should be applied over 
the chest. If the heart is weak, the pulse feeble and rapid, then 
analeptics should at once be administered beginning with a hypo- 
dermic of thirt}^ minims of ether and following with an injection 
of camphor in ether or camphor in oil, as described on pa^e 32. 

As soon as the patient revives from his faint an injection of 
a quarter-grain of morphine with two-hundredth of a grain of 
atropine is given in order to allay restlessness and excitement. 



PULMONARY INFARCT, ABSCESS AND GANGRENE 



305 



If, shortly after the infarction, evidence of pulmonary edema 

begins to appear, then two or three hundred cubic centimeters 

of blood should be withdrawn by venesection from the median 

cephalic vein as described on page 37. If the hemoptysis is 

very abundant then this complication should be treated as de- Venesection 

scribed in the Section on Hemoptysis. The bleeding from the 

lung is rarely very profuse or persistent in pulmonary infarct 

and it is well to remember that infarction of the lungs may occur 

without any hemoptysis. 

If the infarction in any particular case is attributable more 
to thrombosis of branches of the pulmonary artery from the 
right auricle than from embolization originating in some phle- 
bitic process in a remote portion of the body, and if there is 
tangible evidence of cardiac dilatation and insufficiency, then 
cardiac tonics, digitalis at their head (see index) should be 
administered, an ice bag should be applied to the precordium and cardiac tonics 
venesection performed. If, however, the hemorrhage from the 
lungs is very severe, then venesection is contra-indicated. ice bag 

PULMONARY ABSCESS AND GANGRENE. 

In connection with the treatment of pulmonary infarct a 
few words may be said in regard to the treatment of pulmonary 
abscess, for this lesion not infrequently develops as the result 
of pulmonary infarct due to occlusion of a pulmonary ves- p u i m0 nary 
sel by a septic embolus. The symptomatic treatment of pulmon- abscess 
ary abscess dependent upon this cause in the beginning corre- 
sponds to that of any other form of pulmonary infarct. 

In fully developed pulmonary abscess due to septic infarct 
from septic phlebitis or endocarditis, or to any other cause as the 
aspiration of a septic foreign body, purulent breaking down of a 
pneumonic or tuberculous focus, etc., or in abscess occurring as 
a part phenomenon of a general pyemia, internal treatment is 
practically of no avail and the case becomes a surgical one, i. e., 
the indications are created for opening the abscess by pneumot- 
omy and establishing drainage. If there is only a single abscess pneumotomy 
cavity, and if it can be definitely located, the injection of anti- and drainage 
septic fluids, as carbolic acid, iodoform emulsion, menthol, may injection of 
be tried, but this treatment is very uncertain, never without dan- antiseptic 
ger and essentially surgical in character, so that the injection 
treatment of pulmonary infarct need not be discussed in this 
volume. If the abscess cavity ruptures into a bronchus the treat- 
ment becomes synonymous with that described in the Section on 
Bronchiectasis (page 283), if it ruptures into the pleural cavity Rupture of the 
an empyema is created which should be treated according to abscess 
the rules laid down in the Section on Pleuritis (page 331). 

Gangrene of the lungs, finally, may occasionally follow em- Gangrene of 
bolism of the pulmonary artery and infarction of certain areas of e ^ 



306 



HEMOPTYSIS 



Injection of 

antiseptic 

fluids 



Fetor of the 
breath 



Internal rem- 
edies 

Turpentine 
Myrtol 
Eucalyptol 



the lungs. This development, however, is relatively rare and, as 
a rule, gangrene follows pneumonia, bronchiectasis or invasion 
of the lung by a foreign body either via a bronchus or the pleura. 
Here, too, internal treatment is unsatisfactory. Surgery has a 
definite field in the treatment of this disease, as in the treatment 
of abscess of the lung, and here, too, if it is possible to circum- 
scribe the gangrenous area, the injection of a certain antiseptiG 
solution (by a surgeon!) has a place. 

The internist is often called upon to treat certain symptoms. 
The horrible fetor of the breath is an especially disagreeable ac- 
companiment of this disorder. Inhalations of turpentine, laven- 
der oil and tincture of eucalyptus are especially useful, employed 
either singly or combined. From five to ten drops of any of these 
preparations should be poured on hot water and the vapors in- 
haled through a paper cornucopia as described on page 284, or 
a few drops of the various oils may be inhaled through a steam 
atomizer. A two per cent, solution of carbolic acid inhaled in 
the same way is also frequently efficacious in correcting the bad 
breath. 

For internal use the rectified oils of turpentine, myrtol and 
eucalyptol are especially useful. If given in sufficiently large 
doses the expired air soon acquires an odor of turpentine, myrtol 
or eucalyptus, showing that a portion of these remedies is ex- 
creted through the lungs. Whether they act merely as deodor- 
izers or also as disinfectants it is difficult to say. Their adminis- 
tration never does harm and often seems to aid materially in 
restoring healthier conditions. Rectified turpentine oil, myrtol 
and eucalyptol are best given in capsules in two minim doses 
every two or three hours until the breath smells of the drugs. 
It is well, in order to protect the stomach, to give some fat after 
these oils have been taken, or the patient should be ordered to 
drink a glass of milk with cream or to eat a piece of bread and 
butter after each capsule. A very simple plan, too, is to admin- 
ister oil of turpentine directly on bread and butter. 

That the general health and the nutrition of a patient suffer- 
ing from circumscribed pulmonary gangrene should be raised 
to the highest possible standard by plenty of fresh air and a 
nutritious diet, suitable to the functional powers of the patient's 
digestive apparatus, is self-evident. 



HEMOPTYSIS. 

Definition Hemoptysis properly speaking means hemorrhage from any 

portion of the respiratory tract, i. e., the pharynx, trachea, 
bronchi, or the lungs. The hemorrhage may either be due to 



HEMOPTYSIS 307 

rupture or erosion of one of the large blood vessels lining the 
respiratory tract, or to rupture of an artery adjacent to the air 
passages into the lumen of the latter, or it may be due to capil- 
lary oozing, that is, diapedesis of blood through the weakened 
walls of congested veins and capillaries in the respiratory mu- 
cosa. 

Hemorrhage from the lungs may occasionally be a protective Hemoptysis 
process and one that does not call for any interference. This p^ect?ve ly * 
applies particularly to three varieties of hemoptysis, viz., first, process 
hemorrhage occurring before and during the period of menstrua- 
tion; second, hemorrhage occurring in certain heart lesions, 
notably mitral and tricuspid insufficiency; third hemorrhage 
occurring in apparently healthy subjects, usually in adolescents. 

The treatment of hemoptysis occurring before and during Vicarious 
the menstrual period, i. e., vicarious menstruation through the nemo Pty sis 
respiratory passages, is the same as that described under vica- 
rious epistaxis (page 272). An effort should be made to bring 
about bleeding from the uterus by hot vaginal douches, hot 
mustard foot baths, catharsis and the use of emmenagogue rem- 
edies, chief among them Pil. Aloes et Ferri, five grains (0.3 gm.) 
two or three times a day, or cimicifuga, which should be given 
in doses of five drops of the fresh tincture every four or five 
hours for two or three days preceding the expected menstruation. 

Hemoptysis due to pulmonary stasis from valvular disease 
may usually be considered in the light of a "safety-valve" action Hemoptysis in 
inaugurated by Nature to relieve engorgement of the right heart g^ s J 
and embarrassment of the pulmonary circulation. It has its 
analogue in the hemorrhoidal bleeding so frequently seen in 
portal stasis due to obstructive processes (cirrhosis or stasis 
within the liver from heart disease). As a rule this form of 
hemoptysis calls for no intervention. In frequently occurring 
pulmonary or bronchial hemorrhages, however, due to heart Cardiac tonics 
disease with the loss of large quantities of blood, cardiac tonics, 
as described in the Section on Decompensated Heart Lesions 
are the chief remedies to be employed ; and the results from this 
therapy are always satisfactory. 

As a prophylactic measure against such hemorrhages it may Pro P n y laxis 
become necessary to administer some opiate in order to reduce 
the straining effort incident to violent or persistent coughing. 
In other cases if the hemorrhage is so severe as to fill up large 
areas of the bronchial tree so that there is danger of suffoca- 
tion, or if the patient after the hemorrhage experiences great 
difficulty in expelling the blood clots, so that there is danger o? 
secondary infection (pus germs and other bacteria finding a 
suitable nidus for their development in the stagnating and dis- 



308 



HEMOPTYSIS 



Expectorants 
Ipecac 



Hemoptysis of 
adolescence 



Rest and 
avoidance of 
heart tonics 



Hemoptysis 
from ulcera- 
tion in the 
upper air 
passages 



Topical treat- 
ment 



Hemoptysis 
from aortic 
aneurism 



integrating blood), then it may become necessary, as an ex- 
treme measure, to choose the smaller of two evils and to admin- 
ister expectorants. The best remedy in these cases is ipecac root, 
given either in three or four large doses of fifteen grains (1 gm.), 
each, every hour, until vomiting occurs (Trousseau), or in small 
doses of one and one-half grains (0.1 gm.) every ten minutes to 
the point of nausea (Jaccoud). It will rarely become neces- 
sary, however, to adopt this somewhat precarious procedure and 
it must always be considered as a violent emergency measure 
adopted as a last resort to save a suffocating patient. 

Closely related to hemoptysis from valvular disease belongs 
the hemoptysis occurring in healthy adolescents. The patients 
rarely feel any serious discomfort from the hemorrhages, which 
are generally slight. The explanation of these hemorrhages is 
difficult to give. It is probable that in rapidly-growing adoles- 
cents there develops a relative inadequacy of the heart's capac- 
ity due to the fact that the heart cannot keep up with the in- 
creasing labor that is imposed upon it when the body grows 
rapidly. As a result temporary insufficiency with dilatation of 
the ventricles, chiefly of the right heart, relative muscular in- 
sufficiency about the mitral and tricuspid valves occurs with ven- 
ous engorgement in the pulmonary circulation and hemorrhage 
from the lungs. This theory is borne out by the frequent dis- 
covery in such cases of systolic murmurs at the apex and over 
the tricuspid area. The best treatment for this form of hemop- 
tysis is rest and careful administration of heart stimulants and 
heart tonics (see page 38). The young people should be warned 
against excessive exercise and should be instructed to lead a 
quiet life, physically, mentally and emotionally. As a rule the 
heart soon adjusts itself to the increased demands upon its pow- 
ers and the hemoptysis disappears never to return again. 

Hemorrhages from ulcers in the larynx and trachea are 
amenable to the same treatment as hemorrhages in any other ex- 
posed region of the body, provided the bleeding spot can be seen 
through the laryngoscope. Here the same rules apply as in the 
treatment of epistaxis due to similar causes. The hemorrhages 
can often be arrested by the application of a silver nitrate stick 
or of alum powder or, best of all, of the actual cautery, care 
being taken, if the latter is applied, to withdraw the point of 
the cautery while it is still hot, as otherwise the eschar may be 
torn off when the instrument is removed. 

Hemorrhages from aneurism of the aorta are in most cases 
very profuse and rapidly fatal so that no opportunity is given for 
aiiy treatment. If the patient does not succumb at once to the 
loss of blood or to suffocation from flooding of the bronchial 



HEMOPTYSIS 309 

tree with blood, then the treatment becomes the same as that 
in any other form of pulmonary hemorrhage from an eroded 
blood vessel (see below). 

Hemoptysis not due to vicarious hemorrhage nor to heart ^ftm^t 7 f 
lesions and not occurring in an adolescent, under the conditions hemoptysis 
outlined above, but resulting from erosion of an artery (the 
protoype of such a hemorrhage being the hemoptysis of pul- 
monary tuberculosis) should be treated as follows: Upon the 
occurrence of the hemorrhage the patient should immediately be 
put to bed and kept in a sitting or semi-recumbent position, as P 0551 * 1011 
it is easier to expectorate the blood w T hen in this position than 
when lying down. If the loss of blood is so severe that the pa- 
tient faints, then no effort should be made at first to revive him 
by the use of stimulants, as clotting is favored when the patient 
is unconscious. If the loss of blood is not so severe as to pro- 
duce fainting, then above all things the patient's excitement Famtm g 
should be allayed, if necessary by the hypodermic injection of a Morphine 
quarter of a grain of morphine with one-two-hundredth grairi 
of atropine. In some cases it is best to refrain from the use of 
hypodermic medication, especially if the patient is afraid of 
the needle ; in others it is well to insert a hypodermic needle 
if for no other reason than to give the patient the assurance that 
energetic measures are being instituted to save his life. The 
physician in such an emergency must be guided by the tempera- 
ment of the individual patient. 

If a physical examination, rapidly made, or if previous knowl- 
edge of the patient's lungs enables the physician to suspect 
from what part of the lungs the hemorrhage has occurred, and 
especially if there is pain in a circumscribed area of the chest, 
then an ice-bag should be applied over this point. If the bleed- Ice bag 
ing spot cannot be definitely localized in a tuberculous case, then 
it is always safe to apply small ice-bags over the apical region. 
At all events an ice-bag should be placed over the heart in order 
to quiet its reaction and reduce its frequency. A very good plan 
is to apply the ice-bag intermittently over the suspected lung 
area and over the precordium, leaving it in place for an hour. 

Rest in bed, morphine and the application of ice to the re- 
gion of the heart are intended, above all things, to reduce the 
rapidity of the heart's action and to lower the blood pressure. 
The latter purpose can also be fulfilled by the use of aconite 
or of sodium nitrite, the former to be given in drop doses until 
the character of the pulse reveals that the blood pressure has been Aconite 
reduced; the latter in doses of one to two grains (0.05 to 0.1 Sodium 
gm.) repeated every three or four hours. Great care should be mtrate 
exercised not to produce too great depression and if the hemor- 



310 



HEMOPTYSIS 



Stimulants 



Ligation of 
extremities 



Opiates 



rhage is severe and the pulse low and feeble when the patient 
is first seen, it is evident that remedies like aconite and sodium 
are contra-indicated. In the latter cases heart stimulants like 
strychnine, brandy, camphor, coffee, ether may be required to 
save the patient's life. 

Of other general measures that should be employed in pul- 
monary hemorrhage, ligation of the extremities with a bandage 
or a piece of rubber tubing is a useful procedure. The bandages 
or rubber ligatures should be applied so tightly that the venous 
back flow is impeded, while the progress of the blood into the 
limbs through the afferent arteries is not interfered with. The 
ligatures should remain in place from a quarter of an hour to one 
hour. This plan of treatment is intended to reduce the volume of 
blood flowing through the bleeding area and hence to favor co- 
agulation. 

Of remedies that should be given in hemoptysis opiates 
occupy the first place. Opium or morphine may be given either 
by mouth or hypodermically (see above). If the insertion of 
the hypodermic needle does not excite the patient too much, the 
latter plan is by all means preferable. Occasionally the admin- 
Administration istration of opium or morphine by suppository or clysma becomes 
necessary (Dose and administration, see index). Opiates do 
not act as hemostatics but merely stop the cough and hence allay 
straining efforts ; they also counteract restlessness and excitement 
and hence prevent high arterial tension from this source. Theo- 
retically opiates are contra-indicated because they produce con- 
gestion in the peripheral vessels. Their exact mode of action 
upon the pulmonary vessels, however, is not altogether under- 
stood, and as we know empirically that they are highly effica- 
cious in hemoptysis their use can be warmly recommended. 

Of other hemostatic remedies ergot should, above all things, 
be eschewed for reasons that have been explained in full in the 
Sections on Epistaxis and Pulmonary Infarct (page 275). Hem- 
orrhage, in the minds of many practitioners, spells ergot as the 
remedy and however correct ergot treatment may be in hem- 
orrhage from the uterine cavity so incorrect it is in hemorrhages 
from most other portions of the body. 

Tannic acid has been used extensively. It is questionable 
whether it is very trustworthy as a hemostatic in hemoptysis. 
The best form in which to administer tannic acid, and the one 
in which the drug does the least injury to the stomach, is as 
the fluid extract of hamamelis, which should be given in thirty 
minim (2 cc.) doses, in water, every two or three hours. 

Lead acetate, which for a long time was very popular, is 
mentioned to be condemned. Lead acetate acts very well locally, 



Dangers of 
ergot 



Tannic acid 



Hamamelis 



Gelatin 



HEMOPTYSIS 311 

but if given in doses large enough to reach the bleeding spot in Lead acetate 
a concentration that could promote arrest of hemorrhage, gen- 
eral lead-poisoning, nephritis or severe gastro-intestinal dis- 
turbances would assuredly develop. If given in smaller doses 
it would be ineffective as a hemostatic. 

Oil of turpentine given in five drop doses in milk or on bread 
and butter, every two or three hours, is a valuable remedy espe- Turpentine 
cially in slow, persistent bleeding from smaller vessels, and I 
have seen several cases of hemoptysis yield to this treatment 
when all other remedies seemed to have failed. 

The most reliable hemostatic we possess, however, is hydras- 
tis canadensis. It may be given as the fluid extract in doses of Hydrastis 
fifteen to sixty minims (1 to 4 cc), in milk, every hour for four 
or five doses ; as hydrastinine hypodermically in doses of one-half 
to two grains (0.03 to 0.1 gm.) ; as cotarnine (stypticine) in doses 
of one-third to one-half grain (0.02 to 0.03 gm.), in watery solu- 
tion, by mouth or hypodermically every hour for four or five Hydrastinine 
doses or until the desired hemostatic effect is produced. Cotarnine 

Gelatin has been used extensively in hemoptysis. In order 
to be efficacious it must be given in large doses. A very good 
method of administering it by mouth is to prepare a solution con- 
sisting of: 

i* 

Common salt, '1 

Gelatin, 10 

Water, 200 

M. Sig. Of this mixture about one-third is 
given in one dose and two or three table- 
spoonfuls every hour thereafter. 

Sometimes the administration of gelatin hypodermically aids 
in arresting hemoptysis, but this plan can usually only be carried 
out in an hospital where a carefully sterilized gelatin solution 
is ready for immediate use. It is always a dangerous procedure 
to administer gelatin hypodermically or intravenously in pri- 
vate practice, because gelatin is made from the hoofs of animals 
and, unless very carefully sterilized by discontinued steriliza- 
tion on several successive days, may contain live spores of te- 
tanus. Leaving this danger aside, the injection of gelatin at 
best is not an indifferent procedure, for the patients often re- 
act with slight fever and much local pain. For the technique 
of administering gelatin subcutaneously see also the Section on 
Aneurism. 

After the hemoptysis has been stopped the patient should ment 



312 



PULMONARY TUBERCULOSIS 



Diet 



Causal treat- 
ment of slow 
hemoptysis 



remain in bed for some time. It is a good rule to keep the pa- 
tient perfectly quiet until the last traces of blood have disap- 
peared from the sputum. During this time he should be forbid- 
den to speak loudly, to call or to otherwise strain the voice and 
indulge in violent respiratory efforts. 

In order to prevent straining at stool it is always best to 
lock the bowels for several days by the administration of opiates. 
Later evacuation of the bowel contents should be made easy for 
several weeks after the hemorrhage by the administration of 
appropriate laxatives (see index) or the use of enemas. 

In the beginning the patient should be kept on a liquid diet 
consisting, during the first days only, of small doses of ice-cold 
milk given frequently, later gruels, a little fresh fruit and vege- 
tables, soft boiled eggs and, last of all, meat and meat products 
may be permitted. Tea, coffee, alcohol, very hot foods and car- 
bonated beverages should be denied as long as there is any oozing 
of blood. 

The causal treatment, finally, of slow hemoptysis occurring in 
the course of leukemia, the hemorrhagic diathesis and severe 
primary anemia is synonymous with the treatment of the under- 
lying disorder. The symptomatic treatment of this form of 
hemorrhage does not differ from that of any other variety of 
hemoptysis of a slow character. Hemoptysis in pneumonia 
rarely calls for special treatment. 

The treatment of the secondary anemia following severe 
hemorrhages or the continued loss of small quantities of blood 
through slow oozing from the respiratory tract has been fully 
described in the Section on Secondary Anemia. 



Spontaneous 
recovery 



Means of 
treatment 



PULMONARY TUBERCULOSIS. 

Pulmonary tuberculosis in most cases shows a spontaneous 
tendency toward cure or latency provided the proper conditions 
are created for recovery. The main object of treatment, if the 
diagnosis is made early enough, is to secure for the patient ideal 
surroundings adapted to the individual peculiarities of the case, 
to grant the patient the maximum of pure air under suitable 
climatic conditions, and to feed, rest and clothe him properly. 
Medicines play a subordinate role in the treatment of pulmonary 
tuberculosis. There is no specific remedy for the disease (tuber- 
culin, creosote, etc., see below) and drugs should be employed 
only to remedy especially distressing or dangerous symptoms 
and complications and, in the late stages, to render the patient 
comfortable. 



PULMONARY TUBERCULOSIS 313 

Life in the open air when combined with proper feeding and Fresh air 
careful regulation of rest and exercise, when carried out in sur- Diet 
roundings and under conditions that favor a cheerful and hope- 
ful mood and, above all, when carefully supervised and controlled 
by a competent physician, is the best remedy for the cure of pul- 
monary tuberculosis. It is important to realize, however, that 
neither fresh air alone, nor over-feeding alone, nor rest alone, 
can cure tuberculosis of the lung. It is essential that the three 
elements be combined. A phthisical patient may live out doors 
for twenty-four hours during each day and still not improve 
unless his diet is properly regulated, and unless he avoids ex- 
ertion beyond his strength; or he may be over-fed and kept in 
bed and still succumb because the supply of fresh air is insuffi- 
cient and the surroundings remain gloomy and depressing. 

Why abundant fresh air aids so materially in the cure of Rationale of 
pulmonary tuberculosis is difficult to understand. Probably the ? es ? air t 
absence of turbercle bacilli and of pus germs and other bacteria 
that produce mixed infection is an important factor. The open 
air, moreover, contains a much smaller proportion of the noxious 
gases, notably C0 2 , of body emanations and chemical irritants 
that soon pollute the atmosphere of inclosed spaces. Finally, the 
ozone of out-of-doors, the radiation of the sunlight and, above 
all, the psychic stimulus of life near to Nature in open spaces, 
and the improvement of the appetite that results from an open- 
air existence must all be considered important elements. 

To secure an abundance of fresh air all the year round, in Advantages of 
good weather and in bad, in the heat of summer and the cold of Jreatmen? 1 
winter, is a difficult problem. The best conditions are undoubt- 
edly obtained in a closed institution arranged especially for the 
care of tuberculous patients, and here assuredly the most brill- 
iant results are obtained. "Wherever feasible, therefore, the 
tuberculous patient should be advised to enter such an institu- 
tion. The choice of the location, i. e., whether at an altitude or 
at the level of the sea, whether moist or dry, whether hot or cold, 
in other words whether mountain, desert or sea-shore, must be 
made according to the general principles to be presently dis- 
cussed. 

If the circumstances of the patient do not enable him to Home treat- 
enter a private institution of this character, then he should be ment 
taught how to secure open-air treatment at home. Also in such 
cases the sacrifice, pecuniary and otherwise, incident to treatment 
in a closed institution, even if only for a short time, should 
wherever possible be urged. For the educational value of in- 
stitution life is of inestimable value to such patients, especially 
in the present state of deplorable ignorance and scepticism on 



314 



PULMONARY TUBERCULOSIS 



Technique of 
home treat- 
ment 



Room tem- 
perature 



Window tents 



Errors of 
Routine 



the part of the laity in regard to the curative value of such sim- 
ple measures as air, food and rest. A patient who has spent 
even a few weeks in a well-conducted institution soon becomes 
an ardent and enthusiastic convert to the open-air idea, for he 
has been convinced by the good results he has seen, by the tales 
of convalescents he has heard, and he has had the benefit of the 
precepts and the suasion of the medical corps in charge. On re- 
turning from the institution the patient is generally only too 
glad to co-operate in every way with the family physician at 
home. Above all, he has learned to help himself in solving the 
difficult problem of securing the proper arrangements at home 
necessary to continue the plan of treatment begun in the sani- 
tarium. 

Life in a tent placed in the back yard of a city home, or 
on a veranda with southern, southeastern or southwestern ex- 
posures, generally meets all the necessary requirements during 
the greater part of the year. During the rigid winter months 
tent life is usually unnecessarily uncomfortable and a room can 
be easily arranged in which the windows are kept wide open dur- 
ing the day and in which the patient properly clothed (see be- 
low) lives all the time. The room can be kept at a moderate tem- 
perature better than a tent. It is well to realize that air can be 
fresh and wholesome without being uncomfortable. During 
the night any one of the numerous window tents that are in 
the market, or that can be constructed by any carpenter, may be 
used to enable the patient to have at least his head out of doors 
while the body is warmly covered and comfortably tucked away 
in bed. Here the inventiveness and the ingenuity of the phy- 
cian, patient and friends must secure the proper conditions 
adaptable to the surroundings and circumstances peculiar to 
each individual case ; and it would be a futile and superfluous task 
in this volume to discuss all the mechanical devices and to enu- 
merate all the technical details that have been described to ren- 
der the carrying out of the fresh air treatment of consumption 
practicable. 

In recommending this mode of treatment for cases that are 
unable to avail themselves of the benefits of the sanitarium plan 
errors of routine are often committed. The physician who merely 
tells his patients to sleep out-doors or to keep the windows open 
all the year round, errs grievously if he contents himself with 
such general phrases; for it is very important to realize that 
many cases, especially in the beginning of the fresh air treat- 
ment, may become markedly aggravated unless the effect of 
the fresh air, especially during the cold and moist seasons of the 
year, is carefully controlled. 



PULMONARY TUBERCULOSIS 315 

One will quite commonly find that, in the beginning, the Disagreeable 
, . „..; «, , n T !•(» symptoms in 

patients complain of irritation 01 the trachea and bronchi, 01 beginning 

dizziness, insomnia and a general feeling of discomfort. In some, fresn air P lan 
especially during foggy weather, the irritation about the respira- 
tory organs often becomes altogether unbearable, so that increased 
coughing and severe dyspnea supervene. To insist upon wide 
open windows or an out-door life under these conditions is cruel 
and wrong. Such patients should, by all means, be very grad- 
ually accustomed both to the increased amount of out-door air 
and to the greater moisture and lower temperature of the at- 
mosphere they are forced to breathe, and should not be allowed 
to ignore the disagreeable phenomena that make their appear- 
ance and to carry out the rigid fresh air plan despite of them. 
Again, most tuberculous cases are especially susceptible to drafts ; 
this is due to the fact that tuberculosis is often accompanied by 
anemia and profuse sweating. Such patients are very apt to 
catch cold in the beginning of the fresh air treatment and, in this 
way, to have their condition seriously aggravated. 

It often becomes necessary, therefore, as a preliminary to Hardening the 
the continuous fresh air treatment, to subject the patient to a preliminary 1 
carefully regulated hardening process according to the principles 
that have been discussed in full in the Sections on Anemia and 
Acute Rhinitis (pages 79 and 266). For practical purposes the 
following method is very useful, not disagreeable, and, above 
all, never dangerous to the patients. The skin, in the beginning, 
is treated once or twice a day by dry rubbing under covers with 
a rough cloth or the hand. Later the surfaces of the body are 
treated with alcohol, then with alcohol and water and later with 
water that should be lukewarm at first and gradually used cooler 
and cooler until finally the patients can be sponged with water 
of room temperature. The sponging should be carried on under 
blankets, one extremity, the abdomen, back, chest, being treated 
at a time, and should be followed by a brisk alcohol rub. Still 
later the patient may be treated once a day by wet packs of room 
temperature, in such a way that the whole body is quickly wrap- 
ped in a linen cloth wrung out of cool water and covered with a 
woolen blanket. They are allowed to remain in this pack only 
from three to five minutes. The surface of the body is then rub- 
bed dry with a rough towel and treated with alcohol. 

In this way the superficial capillaries are educated to react 
more energetically to sudden temperature changes and the 
tendency to catching cold is materially reduced. At the same 
time the respiration, circulation and the general metabolism are 
greatly stimulated. 

While this hardening process is being carried out, it will 



316 



PULMONARY TUBERCULOSIS 



Intermittent 
fresh air plan 



Clothing 



Choice of 
climate 



When to send 
patients away 
from home 



usually be necessary to render the fresh air treatment inter- 
mittent, that is, to have the patients in the open only during 
certain hours of the day when the sun is shining and to have 
the windows open altogether only on days and nights during 
which the weather is not too cold or foggy, and only partially 
open on stormy days or nights with rain, snow, or violent winds. 
In such weather the patient should be carefully protected from 
the wind by a screen or some other protective device. 

The clothing of tuberculous patients undergoing the fresh 
air treatment should be regulated according to the temperature 
of the air. During warm weather flannel underwear that absorbs 
the moisture from the skin and allows its slow evaporation ; dur- 
ing cold weather wool garments should be worn. Silk or linen 
underwear should never be allowed, for they cling to the skin 
and in this way obliterate the layer of immovable air that should 
intervene between the body surfaces and the first garment (see 
page 267). A sufficient number of woolen blankets should be 
used to keep the patient comfortably warm ; on top of them furs 
may be placed, but furs should never be worn about the neck 
(see page 267). A cap made of wool may be used to protect the 
head and ears during the night, and hot water bags may be 
placed to the feet. It is a very important rule not to have the 
clothing about the chest too tight fitting in order that the respira- 
tion may not be impeded. 

Inasmuch as life in the open air is one of the most import- 
ant factors in the cure of tuberculosis, the choice of a climate 
for tuberculous patients becomes a matter of serious import. The 
ideal climate by all means is the one in which the patient can 
enjoy the maximum of out-door life with the least discomfort. 

Above all, the physician who sends his tuberculous patients 
away from home in order to give them the benefits of another 
climate should consider the circumstances and the accustomed 
mode of life of the patient at home, and should compare them 
with the environment the patient will be forced to live in at 
the resort to which he is sent. If the case is very far advanced, 
or if the patient is in very moderate circumstances, it is usually 
a cruel undertaking to send him away from home and friends, 
away from the physician in whom he has confidence, into strange 
surroundings, among strange neighbors and to a strange physi- 
cian. It is well to remember that climate alone can impossibly 
cure a case of tuberculosis unless the diet and the general mode 
of life are carefully regulated and unless the mood of the pa- 
tient can remain at least as cheerful as it was at home. It i& 
pitiable to see advanced cases of tuberculosis arriving at resorts 
for tuberculosis and eking out a miserable existence at a board- 



PULMONARY TUBERCULOSIS 317 

ing house where they are shunned like lepers (provided they are 
admitted at all) : eating worse food than they received at home 
and living the lives of outcasts among unsympathetic strangers. 
Whoever has seen these poor sufferers sitting dejectedly on the 
curb in the broiling sun of a desert village, under-fed, over- 
exerted, helpless and thoroughly miserable, can hardly suppress 
a feeling of indignation at the almost criminal stupidity of those 
who are responsible for placing the unhappy exiles in such a 
position. It is a thousand times better that such cases should 
remain at home, even in a city and in a cold climate. 

Provided, on the other hand, the patient 's means permit him 
to secure the proper accommodations and diet and good medical 
supervision at the resort to which he is sent, then the climatic 
conditions that will most benefit the patient must be carefully 
considered. Two climates in particular enjoy deserved popu- 
larity in the treatment of tuberculosis, namely, mountain climate 
and Southern climates. Both have their advantages and their 
contra-indications. Some cases do best at moderate altitudes, 
others at the sea-shore or on an ocean steamer, some in the desert 
where the air is dry, others inland where the air is warm and 
moist. It would lead altogether too far to discuss in detail all 
the indications for the choice of climate as they arise in each 
individual case, especially as these indications vary with changes 
in the condition of the patient. The following general rules, 
however, may serve as a guide in the selection of a climate for 
tuberculous patients.* 

Best of all for cases of tuberculosis is mountain climate. Altitude 
Here we have low air pressure, comparatively low temperature, ^? un * am 
slight fluctuations in the daily temperature, dry air, an atmos- 
phere that is flooded with sunshine, that is pure and full of 
ozone and that contains no tubercle bacilli and few pus germs 
or other bacteria. The rarefied air exercises a beneficial in- 
fluence upon respiration and circulation, by forcing the patient 
to breathe more deeply it alters the composition of the blood, 
stimulates metabolism, promotes the action of the skin, increases 
the appetite, and usually induces sound sleep, often, however, 
only after a period of several days or a week of insomnia. 

There are, however, distinct contra-indications to choice of Contra-indi- 

a mountain climate in tuberculous patients. Cases in an advanced catioi i s . to 
. * mountain 

stage of anemia; cases suffering from continuous fever; cases climate 

with empyema, pleurisy or pneumothorax, or with laryngeal 

ulcerations; and patients with valvular heart lesions (see page 

24) should be warned against life at an altitude. 



♦See also Climate in Valvular Diseases of the Heart. 



318 



PULMONARY TUBERCULOSIS 



High altitude 
in winter and 
summer 



Moderate alti- 
tude in spring 
and autumn 



Low altitude 
Dry, warm 
climate 

Desert climate 



Low, moist 
climate 



Seashore and 
island climate 



Best 



The best time to send tuberculous cases to an altitude is in 
winter. While it is very cold in the mountains the air is dry 
and there is rarely much wind, hence the cold is not so percep- 
tible as in lower altitudes; the clear skies and abundant sun- 
shine and the absence of much fog or mist, moreover, render a 
sojourn in mountain resorts more pleasant and more beneficial 
than in warmer regions in the valleys or the plains. In the 
heat of midsummer too high altitudes are not useful for obvious 
reasons. During the Spring and Autumn it is best to send pa- 
tients to moderate altitudes rather than to high altitudes. This 
applies particularly to those who are sent to a resort for the first 
time in spring or autumn, for here sojourn at a moderate alti- 
tude, not to exceed 3,000 feet, for a time forms a beneficial 
transition to life at a higher altitude during the coming winter 
or summer months. 

Life at a low altitude or at sea level may be considered in- 
different as far as its effect upon the human organism is con- 
cerned. Here the temperature, the amount of sunshine and, 
above all, the amount of moisture in the air are the determin- 
ing factors. Broadly speaking a dry climate at sea level has a 
mildly stimulating effect, whereas a moist climate at sea level has 
a mildly sedative effect (see page 24). 

A dry warm climate at a low level is especially useful in 
tuberculosis if there is an abundant secretion from the bronchi ; 
such patients do especially well, as a rule, 'in a desert climate 
where there is also abundant sunshine and where the air is 
essentially free from pus germs. The latter element is very 
important, for most cases suffering from profuse expectoration 
are afflicted with a mixed infection. Life in the desert on ac- 
count of the absence of pus germs in the air often aids mate- 
rially in converting such a mixed infection into a simple tuber- 
culous infection. This is an exceedingly desirable effect. High 
mountain climate shares this advantage with the desert and mid- 
ocean. 

To the category of low, moist climates belong chiefly sea-shore 
and island climates. Here the air is pure, contains a large pro- 
portion of oxygen, considerable moisture and salt, and a small 
amount of carbon dioxide. The moisture of the air and the 
salt it contains exercise a mildly stimulating effect upon the bron- 
chial mucosa and the skin. The low pressure strengthens and 
retards the heart's action and induces deep, slow respirations. 
Appetite and sleep are usually improved in these climates. 
Very anemic patients, however, rarely do well at the sea-shore, 
for reasons that have been fully discussed in another section. 

Rest is an element that is of the greatest importance in 



PULMONARY TUBERCULOSIS 319 

the treatment of tuberculosis. Consumptives, in the beginning, 
especially if they are suffering from a recent tuberculous infec- 
tion with high fever, immaterial whether they live out of doors 
or in, should be kept absolutely at rest and quiet, i. e. : they 
should remain all day and all night in a recumbent or a semi- 
recumbent position. This also applies with particular emphasis 
to cases of tuberculosis that have had one or more attacks of 
hemoptysis or are very anemic. 

As soon as some improvement has occurred and the tempera- Exercise 
ture is low or normal (the sputum free from blood and the 
anemia improved) the patient should be allowed to walk on the walking 
level for a little time once or twice a day, beginning with short 
walks of not more than ten or fifteen minutes; they may then 
gradually be allowed to increase the amount of exercise accord- 
ing to the reaction they show. Shortness of breath, palpitation, 
dizziness, sweating are all danger signals indicating that the 
amount of exertion is too great. A tuberculous patient should 
never be allowed to exercise to this point. Later, as the im- 
provement continues, very gradually controlled hill climbing 
may be permitted. In some resorts a regular Oertel-Terrain sys- Hill climbing 
tern (see page 23) is arranged and the amount of exercise care- 
fully regulated by this means. While walking the patient should 
breathe deeply and with great regularity, an object that is best 
accomplished by instructing him to take a deep breath through 
the nose with each step. 

In selecting the diet for a tuberculous patient an attempt Diet 
at over-nutrition should always be made. Mathematically ex- 
pressed, a sufferer from tuberculosis should receive instead of 0v er nutrition 
the ordinary thirty to thirty-five calories per kilo each twenty- 
four hours (see page 114) at least forty-five calories. In well 
managed institutions the regulation of the diet is carried out 
according to calorimetric methods. In private practice and in 
most resorts feeding, owing to the difficulty of carefully per- 
forming metabolic studies, is generally carried out according to 
empiric rules, some of them very crude, very one-sided and very 
wrong. 

The tastes and idiosyncrasies of the patient should always Tn e diet 
be very carefully considered and every endeavor should be ad- should be pal- 
vanced to render the diet palatable and agreeable. One of the Forced f ee dino- 
most serious obstacles encountered in the forced feeding of 
tuberculous cases is the lack of appetite and the aversion to 
food (see below) that so many of these patients develop after 
» time. To avoid this is a fine art which should be cultivated. 
The diet should not be too one-sided nor monotonous, but should 
incorporate the greatest variety of food, prepared in a tempting 



320 



PULMONARY TUBERCULOSIS 



Meat 



Fat 



Eggs 



Milk 



Fruits and 
vegetables 



Beverages 
Alcohol 



form, preference, of course, being given to those articles of 
diet that possess the greatest nutritive (caloric) values. 

The chief article of diet should, by all means, be meat, for 
it is a well known fact that carnivorous animals and peoples 
living on an abundant meat diet are much less susceptible to 
tuberculous infection than herbivorous animals and vegetarians. 
At the same time, abundant fat should be supplied in the form 
of cream, butter, bacon, olive oil in salad dressing or in mayon- 
naise, sardines, etc. In selecting meat those varieties contain- 
ing abundant fat should be given the choice; and the meats 
should be prepared with plenty of fat. 

Eggs are a very valuable article of food and a convenient 
vehicle for supplying abundant nitrogen. They are best eaten 
either boiled or poached or in soups, sauces or omelets, or as an 
addition to milk as egg-nog. There is no particular advantage, a 
popular prejudice to the contrary notwithstanding, in using 
them raw. In some institutions enormous quantities of raw 
eggs are administered as a routine, with the result usually of 
thoroughly disgusting the patients so that they cannot take 
eggs at all after a time, and without doing them any particular 
good that could not be obtained by having them prepared in a 
more tempting form; for no article of food can be made more 
palatable, and prepared in more different ways, than eggs. 

Milk is also a very useful article of diet and should be used 
liberally in the preparation of vegetables, sauces, gravies, etc. 
As a food between meals milk is also very useful, especially in 
the form of egg-nog or milk-cream mixture (two-thirds milk, 
one-third cream, one tablespoonful of lime water). Many people 
have a distinct aversion to milk and it is worse than useless to 
try to force them to drink it. Occasionally one can accustom 
patients to milk by serving it in small quantities and very cold, 
or with a little brandy. An attempt should always be made to 
do this. Some patients can drink milk without distaste but 
complain of a feeling of satiety even after taking small quan- 
tities, so they are utterably unable to swallow anything else with 
relish. In these cases, too, the administration of milk should 
be avoided or greatly curtailed, as otherwise over-nourishment 
of the patient becomes impossible. 

Fruits and vegetables of any kind are allowed, preference 
being given to vegetables containing large quantities of albu- 
men, as peas, rice, beans, etc. Plenty of milk, cream, butter, 
flour should be used in preparing all vegetable dishes. 

Of beverages, cocoa, chocolate, tea, coffee, bouillon, broths, 
meat extracts, buttermilk are all useful. Alcohol, too, is a food 
which should not be omitted from the bill of fare of tuberculous 



PULMONARY TUEERCULOSJS 321 

m 

cases. It is best given in the form of dilute spirits or claret, or 
light wines diluted with water. Beer, owing to the percentage 
of carbohydrate it contains, is a particularly useful beverage 
and may be taken with impunity. It is especially useful in 
the evening on account of its slight soporific effect. Brandy or 
whisky as an addition to egg-nog is also useful. Strong alco- 
holic liquors, like straight whisky or brandy, should be avoided, 
especially in cases suffering from tachycardia or ulcerative pro- 
cesses in the larynx or digestive tract. That there are occa- 
sionally distinct contra-indications to the use of alcohol, espe- 
cially in sufferers from cardio-renal disease and arterio-sclerosis, 
need hardly be emphasized. 

Medicamentous Treatment. The treatment of tuberculosis Specific treat- 
with products made from the tubercle bacillus, i. e., tuberculin men 
and its various congeners, is still to be considered as in an ex- 
perimental stage. Clinicians who have worked for years with 
these products report results that are greatly at variance, some 
claiming good effects in all cases, others indifferent effects in 
most cases. In resorts in which the use of tuberculin and similar Tuberculin 
products is combined with rest, proper feeding and an out-door 
life the results seem to be fairly good, but here it is very diffi- 
cult to determine how much of the benefit is to be attributed to 
the "rest, the diet and the fresh air, and how much to the "spe- 
cific" remedy. 

From what experience I have had with this remedy in hos- 
pital practice and from what I can glean from the literature, I 
am inclined to think that tuberculin possesses some curative 
value if properly used ; but that this substance is also very dan- curative value 
gerous unless administered in very small doses and under very 
careful control.* Tuberculin should be used in small doses, so 
small that no reactive symptoms (i. e., fever, signs of local irrita- Dosage 
tion in the affected area, general lassitude, headache, pain in 
the joints, etc.) appear. The dose may be gradually increased 
until these symptoms appear and then it should be immediately 
reduced and the patient kept on a quantity slightly below that 
at which a reaction occurred. It is manifestly a difficult matter 
to determine the onset of a "reaction" in a febrile patient, so 
that this index is useful only in quiescent cases. Here a latent 
tuberculous process may be rekindled by the injudicious use Dangers of 
of tuberculin for therapeutic or for diagnostic purposes so that tuberculin 
at best the remedy is dangerous. Moreover, quiescent cases usu- 
ally get along very well with proper hygiene and without snecific 
medication with tuberculin, so that the remedy in those cases 
precisely in which it could be used with some probability of 

*The new method of determining the opsonic index has rendered the 
use of tuberculin much more safe and accurate. 



322 



PULMONARY TUBERCULOSIS 



Creosote and 
its derivatives 



Mode of action 



Effects 



Contr a-indi ca- 
tions to creo- 
sote 



success is not only dangerous in careless or unskilled hands but 
also superfluous. 

If used at all the initial doses should not exceed one-tenth 
mg., and in no case should the maximum dose exceed 0.01 to 0.02 
gm. Personally, I have, however, abandoned the use of tuber- 
culin altogether. My main objection to its employment being 
the uncertain strength and unstable composition of practically 
all the tuberculins and, finally, the observation that the results 
obtained from proper hygiene, diet, fresh air and rest with tuber- 
culin are no better than those obtained by the same means with- 
out tuberculin. 

A remedy that has for many years enjoyed popularity in 
the treatment of tuberculosis is creosote and its derivatives, 
guaiacol, creosol and cresol. While this remedy can, in no sense, 
be considered a specific, it certainly does good in most cases of 
tuberculosis and its use is therefore to be recommended. 

Its exact mode of action is difficult to explain. It can hardly 
be said to possess specific anti-bacterial action against the tuber- 
culosis germ, for animals treated with creosote and subsequently 
tuberculized succumb to the infection as readily as animals that 
have not previously been treated with creosote. Again, the 
sputum of tuberculosis cases, that have received large doses of 
creosote for a long period of time, contains as many and as 
virulent tubercle bacilli as that of patients who have not re- 
ceived the benefits of creosote treatment. 

However obscure its pharmacological action may be, we know, 
clinically, that it increases the appetite, improves gastric and 
intestinal digestion and aids assimilation, hence improves the 
general nutrition and increases the strength of the patient ; that 
in most cases it relieves the cough, reduces the fever and stops 
the night sweats. The remedy is particularly useful in early 
stages, but it should also be given a fair trial in advanced cases. 

There are distinct contra-indications to its use. Some indi- 
viduals are altogether intolerant to the drug and react to the 
administration, even of small doses, by severe signs of intoxica- 
tion, notably violent gastro-enteritis with vomiting and purging, 
dizziness, fainting and profuse sweats. Upon the appearance of 
such symptoms the administration of the drug should, of course, 
not be insisted upon. In other cases the symptoms of creosote 
intoxication are less severe and manifest themselves by milder 
symptoms of gastric and intestinal irritation, such as burning in 
the epigastrium, belching, loss of appetite, slight colic and diar- 
rhea. In many cases as the patients become accustomed to the 
use of the drug these symptoms disappear, so that the administra- 
tion of small dosevS may for a few days be tentatively continued, 



PULMONARY TUBERCULOSIS 323 

intermittently, in the hope that the patient will gradually tol- 
erate the remedy. The slight discomfort from the stomach aris- 
ing during this trial can well be borne in view of the benefits 
to be expected from creosote if it can be taken at all. 

Many preparations of creosote and its derivatives have been Dose and ad- 
recommended. If creosote itself is to be taken, it is best given minis *ration 
by mouth in gelatin capsule with a little cod liver oil, for in- 
stance : 

Creosotis 0.1 

01. Jecoris aselli 0.3 

M. One hundred such capsules. 
Sig. Five to ten capsules daily at meal time. 

Or the creosote may be given in wine, as follows : 

Creosotis, 13.5 

Tinctura gentianae 30.0 

Spiritus vini, 250.0 

Sherry qs. ad. 1000.0 

Two tablespoonf ids after each meal with a little 
water. — (Bouchardat and Gimbert.) 

Or it may be given in five to ten drop doses in a tablespoonful 
of cod liver oil several times a day; or by rectum 
in a milk or milk-egg enema, in such a way that thirty drops 
of creosote are dissolved in 300 cc. of warm milk to which are 
added one egg and a few drops of opium. 

Two preparations of creosote that, in my experience, are Creosotal 
better than creosote are creosotal and thiocol, the former being Thloco1 
a yellowish liquid that is non-irritating and non-toxic (excepting 
to patients with an idiosyncrasy to creosote) even when given 
in large doses. It is given in drop doses in milk or water, be- 
ginning with twenty drops three times a day and increasing the D 0se and ad- 
dose to a tablespoonful three times a day during meals. The lat- ministration 
ter is a powder that can be given in doses of forty-five to sixty 
grains (3 to 4 gm.) a day in capsule or powder, best during 
meals, without producing any gastric or intestinal irritation. A 
very convenient method of administering creosotal is to give it 
in gelatin capsules, each containing twenty to thirty drops, four 
or five of these capsules being administered a day. Some pa- 
tients prefer to have the remedy administered in one dose a 
day per rectum, especially if they are taking other medicine 



324 



PULMONARY TUBERCULOSIS 



Guaiacc 



Remedies of 
historic in- 
terest 



Arsenic 



Dose and ad- 
ministration 



by mouth. Here a good plan is to mix 10 ce. of creosotal with 
yolk of egg, to stir this mixture into 300 cc. of warm milk, to add 
a few drops of tincture of opium and to inject this quantity into 
the rectum through a high rectal tube. 

Guaiacol is a useful derivative of creosote that is very popu- 
lar. It may be given as the carbonate, benzoate or salicylate of 
guaiacol in powder form, beginning with five grains (0.3 gm.) 
three times a day and increasing the dose until as much as fifteen 
to thirty grains (1 to 2 gm.) three times a day are being taken. 
These guaiacol preparations are decidedly more irritating when 
taken by mouth than either creosotal or thiocol. 

Innumerable other remedies have at different times been 
recommended as specifics in the treatment of tuberculosis, but 
none of these has vindicated its claim to usefulness in this 
disease. Among the remedies that possess the greatest historic 
interest and that created much sensation at the time when they 
were first recommended are cinnamic acid and its derivatives 
hetol and sodium cinnamate, copper and its salts, and nuclein. I 
have never been assured that these drugs are of any use what- 
ever in the treatment of tuberculosis. 

Arsenic is a remedy that possesses no specific power over 
the tuberculous process but may to advantage be used in tuber- 
culosis as a general tonic. It may be given in the form of 
Fowler's solution by mouth, beginning with three to five drops 
in plenty of water three times .a day and increasing the dose a 
drop per dose a day until fifteen to twenty drops, three times 
a day, are being taken. Then the amount should be gradually 
reduced until only three to five drops, three times a day, are 
again being administered; the same cycle should be repeated 
several times. The maximum dose must be determined some- 
what by the reaction of the patient to the remedy. If signs of 
arsenic intoxication, puffiness about the eyelids, epigastric dis- 
tress, colic, diarrhea, itching about the palms of the hands and 
soles of the feet appear, then the quantity should be reduced. 
Arsenic may also be given by mouth in the form of sodium ar- 
seniate in the dose of one-one-hundred-and-fiftieth to one-fiftieth 
of a grain, in capsule with sugar of milk, three times a day, for 
indefinite periods of time. Sodium cacodylate, hypodermically, 
is one of the best preparations if it is desired to administer large 
doses of arsenic without danger of intoxication. It is particu- 
larly useful, aside from its action as a general tonic, in aiding 
absorption of pleuritic exudates forming in the course of pul- 
monary phthisis. It is unnecessary to give more than one-fourth 
of a grain of sodium cacodylate in watery solution, hypoder- 
mically, once a day, although as much as one grain, several times 



PULMONARY TUBERCULOSIS 325 

a day. may be given. The patients complain very shortly of a 
peculiar garlic odor of the breath and should be apprised of 
the probable occurrence of this phenomenon when cacodylate 
injections are made. For contra-indications to the use of ar- 
senic and details of administering the different preparations see 
also the Section on Anemia. 

In addition to these remedies various medicinal substances Codliver oil 
are given in tuberculosis more as foods and to replace tissue 
waste than as drug's. Among these codliver oil is the most pop- 
ular. It is questionable whether the iodine it contains, or the 
alkaloids it is said to incorporate, in any way determine its 
good effects in tuberculosis. It is more probable that the fat 
acts beneficially as a food (see page 114). Codliver oil, moreover, 
•is a very convenient vehicle for the administration of a number 
X)f remedies (see above) and as the laity have been educated 
to have much faith in codliver oil, its administration generally 
exercises a beneficial psychic effect that is by no means a neg- 
ligable quantity in the treatment of tuberculosis. 

The administration of different salts is always indicated in Salts 
tuberculosis, for in this disease the urinary and fecal excretion 
of mineral constituents especially of the calcium salts, chlorides 
and phosphates,* is exceedingly large. This loss should be re- calcium 
placed artificially, hence tuberculous patients should receive chlorides 
abundant table salt with their food and should receive phos- phosphates 
phates and calcium salts medicinally. The latter can conve- 
niently be administered in the form of calcium hypophosphite 
or as Syrup of Hypophosphites containing hypophosphite of 
calcium, potassium, sodium, free hypophosphoric acid, spirits of Hypopkos- 
lemon and sugar in the dost of one to two drachms (1 to 8 cc). 

Symptomatic Treatment of Special Symptoms. Provided the 
fever in tuberculosis does not yield to rest, proper feeding, 
plenty of fresh air and the use of creosote preparations, or if 
the patient reacts to even slight elevations of the temperature by 
especially disagreeable subjective sensations, such as profuse 
sweating, great prostration, chills, headache, nausea; or if, fin- 
ally, the fever remains persistently high so as to render it difficult 
to maintain the patient's general nutrition, because the con- 
sumption of his own tissues is so active, then the symptom fever 
must be specially treated. 

A very simple and generally efficient means of combating A , , 
. „ Alconol 

slight rises of temperature is the administration of alcohol, pre- 
ferably in the form of hot toddy, whenever the premonitory 

*See Croftan: The Urinary Calcium Excretion in Tuberculosis, Jour- 
nal of Tuberculosis, 1901. 



Fever 



326 



PUL.MONABY TUBERCULOSIS 



Antipyretics 



Hydrotherapy 



Night sweats 

Alcohol, alum, 
vinegar, sul- 
phuric acid 
washes 



signs (chilliness, hot flushes, etc., of a febrile attack occur), also 
in the form of light Burgundy or Moselle wine as a table bev- 
erage. Early cases of tuberculosis, in my experience, are not so 
apt to develop so much fever, and especially very high degrees 
of temperature, if they take some alcohol as when they do not. 

Sometimes it becomes necessary to combat the fever by the 
use of certain members of the antipyretic group, namely, acet- 
anilid, phenacetin, antipyrin, pyramidon or lactophenine. 
Acetanilid, phenacetin, antipyrin and pyramidon while effective 
in reducing the temperature are very liable to produce disagree- 
able sweating. Lactophenine does not seem to possess this prop- 
erty, hence it should be the remedy of choice (see index). 
Lactophenine and the other remedies enumerated above are best 
given in three to five grain doses about three or four hours be- 
fore the rise of temperature is expected, i. e., as a prophylactic. 
This method of administering antipyretics is much more elegant 
and more efficacious, and moreover requires much smaller doses, 
than if the drugs are given at the height of fever. 

Hydrotherapy is not so useful nor so safe in the reduction 
of tuberculous fever as in the reduction of fevers due to other 
infections. Only very mild hydrotherapeutic measures should 
be employed in any case. Best of all is sponging the different 
extremities, the abdomen, chest and back, singly, with water of 
room temperature, either exposing each part of the body for 
a short time and immediately drying and covering it, or spong- 
ing underneath the covers. Often it is best to merely rub the 
hands and feet, legs, arms and trunk with the hand that is re- 
peatedly dipped in cold water, taking each part of the body 
singly, rubbing dry promptly and following the wet rub by an 
alcohol rub and friction. Or a towel may be wrung out of cool 
water and placed on one extremity and the limb or arm rubbed 
or slapped through the wet towel. This practice is kept up for 
a minute or two, the wet towel removed, the limb quickly dried, 
rubbed with alcohol and dried again. Bath treatment or more 
active hydrotherapeutic means are generally objectionable in 
tuberculosis and should be avoided. Cleansing baths, so nec- 
essary in cases suffering from profuse night sweats, are always 
best given in bed with the patient lying down. Here lukewarm 
water should be used and the bath followed by a brisk alcohol 
rub and massage. 

The night sweats of tuberculosis often call for special treat- 
ment. Here the old fashioned remedy of washing the surfaces 
of the body with alcohol and water, or vinegar and water, or 
with a one to thirty solution of alum, or a one to two hundred 
solution of sulphuric acid, are all useful. 



PULMONARY TUBERCULOSIS 327 

Of recent years formaldehyde, in 40 per cent, solution, mixed Formaldehyde 
with equal parts of alcohol, has been extensively employed. This 
preparation is remarkably efficacious in stopping the sweating 
in any part of the body and its effect usually lasts for several 
nights. Unfortunately the pungent and irritating odors of for- 
maldehyde are disagreeable and may become dangerous to the 
patient, hence in making these applications the windows should 
be wide open and the patient should breathe during the appli- 
cation through a cloth or a sponge saturated with turpentine. 

A useful dusting powder to control the night sweats of Tannoform 
phthisis is tannoform. This should be powdered over the whole 
body every night. Salicylic acid and talcum powder mixed Salicylic acid 
in the proportion of one to one hundred also forms a useful dust- 
ing powder. When this preparation is applied the patient should 
cover his mouth as the salicylic acid is exceedingly irritating 
to the throat and may produce violent coughing. 

For internal use alcohol in the form of brandy or whisky Alcohol 
in milk or water, given in the evening, is occasionally valuable 
in stopping profuse perspiration during the night. Atropine in 
large doses, that is, in one dose of one-fiftieth of a grain (0.0012 ro P me 
gm.), hypodermically, or in two or three one-one-hundred-and- 
twenlieth grain (0.0005 gm.) doses at one hour intervals, by 
mouth, before going to sleep is very useful. Some patients, 
however, cannot tolerate atropine without serious discomfort 
and complain of the dryness of the mouth and throat following- 
its administration. In such cases agaricin in one-twelfth to one Ao> . . 
grain (0.006 to 0.065 gm.) doses in pill form is an exceedingly 
useful remedy, or camphoric acid in fifteen to thirty grain (1 to Camphoric acir* 
2 gm.) doses may be given in a powder or a capsule before the 
patient goes to sleep. 

The cough in pulmonary tuberculosis frequently calls for Cough 
special treatment. If it is due to local causes in the pharynx, Local treat- 
the larynx or trachea, then appropriate topical treatment, i. e., ment 
cauterization of ulcers or the application of lactic acid or in- 
sufflations of iodoform should be employed. The topical treat- 
ment of tuberculous lesions of the upper air passages should be 
left to the skilled specialist and the technique of this therapy 
need not, therefore, be described in this book. The internist, 
however, should always carefully examine the upper air pass- 
ages for ulcers or erosion, as otherwise cough medicines, opiates, 
etc., that may harm the patient, upset his digestion and derange 
his nerves may be given in vain when simple treatment of the 
local condition would promptly lead to the goal. 

Occasionally coughing can be symptomatically relieved by in- inhalations 
halations of steam through a steam inhaler, as described in the 



;J28 



PULMONARY TUBERCULOSIS 



Demulcent 
drinks 



Lozenges 



Education 



Section on Bronchitis. Here sodium chloride or sodium carbon- 
ate added to the water exercise a very beneficial effect. Or the 
patient may inhale the steam from a bowl of hot water through 
a paper cornucopia, or simply by covering his head and the dish 
with a towel, the water being medicated with a teaspoonful of 
tincture of benzoin, or twenty drops of opium tincture with five 
drops of belladonna tincture to the quart. Demulcent bever- 
ages and lozenges also frequently give relief, especially if the 
cough is due to local irritation in the upper air passages. A 
very useful demulcent beverage is the following: 



Narcotics 



Opium and its 
derivatives 



Expectorants 



Oleoresins 
Balsams 



^ 



Sweet almond oil, 
Mucilage, 
Simple syrup, 
Water, 



10 

10 

10 

200 



Lozenges medicated with eucalyptus, guaiacol, menthol, chlo- 
ride of ammonia, red gum are all useful. 

If these simple remedies fail to relieve the cough, then med- 
icines must be given internally. In the absence of much secre- 
tion, i. e., when the cough is irritative in character but non- 
productive then the education of the patient is frequently an 
important element in the treatment. Sufferers from any bron- 
chial or tracheal trouble are apt to cough much more frequently 
and more violently than is necessary. If they are told to sup- 
press or control the cough, when they feel a little tickling in the 
throat or in the chest, very much will be accomplished. Tuber- 
culous cases especially should be educated to cough as gently as 
possible as there is always danger of hemoptysis and spreading 
of the tuberculous process into remote regions of the lung by 
too violent coughing efforts. In the irritative form of cough 
without much expectoration that cannot be controlled by the 
will narcotics must generally be used, especially if the patient 
cannot sleep on account of the coughing, or if the coughing in- 
terferes with his eating, destroys his appetite or causes vomit- 
ing. Here the whole array of opiates, opium, heroin, codeine, 
morphine, dionin, may be employed, as described in full under 
Bronchitis. 

If, on the other hand, the secretion is very abundant, or 
if there are cavities filled with secretion, then opiates should be 
given very sparingly. Here the various expectorants that have 
been fully described in the Section on Bronchitis should be 
employed (see page 282). If the secretion is very purulent, then 
the balsams and oleoresins should be used as in any other form 
of putrid bronchitis. 



PULMONARY TUBERCULOSIS 329 

Patients with large cavities who suffer particularly from 
severe coughing paroxysms at night should be instructed to at- 
tempt evacuation of the cavity by lying on the opposite side to 
it for a time before going to sleep. If this is done evacuation of Position of pa- 
the cavity is promoted and there is less tendency to a paroxysm tients Wlth 
of cough for some hours to come, i. e., until the cavity fills up 
again and its contents comes in contact with healthy bronchial 
mucosa near the orifice of the cavity. The treatment of tuber- 
culous cavities does not otherwise differ from that of bronchiec- 
tasis as fully described on page 283. 

The digestive disorders occurring in the course of tubercu- Digestive dis- 
losis are of great importance and should be carefully considered <> rders 
in the treatment because so much depends on the proper feed- 
ing of tuberculous subjects. If there are marked gastric dis- 
orders, then a careful study of the gastric function should be Gastric dis- 
made and the diet and medication arranged accordingly. In ur ances 
tuberculosis any variety of gastric disorder may occur from sim- 
ple nervous dyspepsia to different combinations of motor, sen- 
sory and secretory perversions, acute and chronic catarrhs, ulcer- 
ative processes with stenosis and dilatation or atony of the gas- intestinal dis- 
tric walls and amyloid degeneration of the gastric and intestinal ord ers 
mucosa. It will be seen, therefore, that the treatment of the 
stomach will : have to vary greatly in each case according to 
the exact character of the trouble that is found. 

Anorexia is a symptom that requires special discussion. ^ norexia 
It may occur in any of the above gastric disorders complicating 
tuberculosis, or it may occur without any marked stomach trou- 
ble. It is always a difficult condition to deal with. 

A tuberculous subject suffering from lack of appetite or selection of 
positive aversion to food should be allowed the widest choice diet 
in the selection of his diet, provided there are no distinct contra- 
indications, as revealed by the state of the gastric function to 
the use of certain articles of food that he may crave. Many 
cases of anorexia are produced by one-sided and forced feed- 
ing, so that here it is particularly important that the physician 
should not be a dogmatic doctrinaire. There are some cases 
in which the patient declares an aversion towards food of any 
kind and manifests an absolute unwillingness to eat. In such 
instances it may become necessaiy to insist upon forced feeding, Forced feeding 
the patient taking his food as he takes his medicine and, here, 
the diet may have to be one-sided but it should, above all things, 
be of the most nutritious kind. In extreme types of anorexia, 
especially in hysterical subjects, it may become necessary to ad- 
minister food by the stomach tube, the nasal catheter, or even by „ A . x t 

... " Stomacn tuoe 

rectal injection (see index), in order to prevent the patient from Rectal feeding 



330 



PULMONARY TUBERCULOSIS 



Exclusive 

milk-cream 

feeding 



Raw beef 



Causal treat- 
ment of an- 
orexia 
Fever 



Coughing 
Pain on swal- 
lowing 



Stomachics 
and bitter 
tonics 



literally starving to death. Most of these cases soon elect to eat 
properly rather than be subjected several times a day to the 
ordeal of artificial feeding. 

In ordering an exclusive milk diet it is best to give a mixture 
of milk and cream, about two-thirds milk and one-third cream 
with a teaspoonful of brandy and a tablespoonful of lime water 
to each tumbler full. This mixture may be given every two 
or three hours during the day. If administered cold the pa- 
tients rarely object to this one-sided feeding. If raw meat is 
given, and this food seems to be of particular value in tubercu- 
losis, then at least 200 grammes of meat should be used in the 
twenty-four hours. The best method of preparing it is to scrape 
the raw beef, to grind the pulp in a mortar and then to press 
it through a sieve. It may be rendered palatable by mixing with 
mashed potatoes and seasoning with plenty of salt, or it may be 
mixed with one or two eggs and flavored with pepper and salt 
or with lemon juice. 

Every case of anorexia should be submitted to careful'study 
and the cause of the aversion to food discovered if possible. 
Sometimes the high fever itself disturbs the appetite of the pa- 
tient, then every effort should be made by the judicious em- 
ployment of antipyretics and of hydrotherapeutic means (see 
above) to keep the fever down. Often the administration of 
five grains of lactophenine, two or three hours before each meal 
time, will accomplish the desired result. In other cases the 
coughing interferes so much with eating that the patients prefer 
not to eat at all. Here a little codeine or dionin, or in extreme 
cases a hypodermic of one-fourth grain of morphine with one- 
two-hundredth of atropine may be given about an hour before 
each meal. In still other cases there is so much pain on swal- 
lowing that the patients refuse to eat for this reason. Cocaine 
employed locally on cotton pledgets, as a spray, or by insuffla- 
tion occasionally relieves the pain and enables the patient to 
swallow. In less severe cases cold must be applied to the throat, 
both externally by the application of ice cloths and internally 
by swallowing ice pills. In all these cases a liquid diet consist- 
ing o£ broths, predigested food and the milk-cream food described 
above, may be given. Very hot, highly seasoned liquids should, 
of course, be avoided. Cases suffering from tuberculous ulcera- 
tion of the larynx and the epiglottis can often swallow better 
ii' lying on their stomach and sucking the liquid food through a 
straw. 

Stomachics and. bitter tonics are of very little value in im- 
proving the anorexia in tuberculosis. Five to ten drops of the 
tincture of nux vomica, or a teaspoonful of the compound tine- 



PLEURITIS 331 

tare of cardamoms or of gentian after meals can, however, do 
no harm. 

The treatment of the constipation that not infrequently de- Constipation 
velops in tuberculosis, especially if one-sided albuminous feed- 
ing is adopted and much opiate is given, will be found described 
elsewhere. Tuberculosis cases eating an abundant amount 
of fat food, however, rarely suffer from very obstinate 
constipation. 

Diarrhea, intestinal fermentation and meteorism must be Diarrhea 
treated as described in the appropriate chapters, The diarrhea 
of tuberculosis is a particularly obstinate symptom and dan- 
gerous, especially if it is due to ulcerative processes in the bowel 
or to amyloid degeneration of the intestinal mucosa. 

Insomnia, in tuberculosis, is, as a rule, due to the cough, the insomnia 
fever or to the pains, pleuritic or otherwise, about the chest, 
or to digestive disorders, flatulency, meteorism, etc. With the 
removal of these causes insomnia usually improves. If it does 
not, then the sleeplessness must be treated symptomatically with 
the aid of remedies described on pages 35 and 36. 

The treatment of the hemoptysis of pulmonary tuberculosis Hemoptysis 
has been discussed in full in the Section on Hemoptysis. 

III. DISEASES OF THE PLEURA. 
PLEURITIS. 

From a therapeutic standpoint the etiological and anatomic 
classification of the different forms of pleuritis is of very little 
value. It is clinically often a very difficult matter to differen- 
tiate between fibrinous, sero-fibrinous and fibrous pleurisy, for 
the reason that small amounts of fluid in so-called dry pleurisy 
frequently escape detection, and because many cases of fibrinous 
or fibrous pleurisy very gradually develop into exudative forms 
with liquid in the pleural cavity. 

The opinion is prevalent that most cases of simple primary ]y[ os t cases of 

pleurisy are tuberculous in character. Hence the causal treat- sim P le pleurisy 

tuberculous 
ment would be the same as that described in the Section on Pul- 
monary Tuberculosis. 

There remain a small minority of cases of pleurisy that are 
not tuberculous and that follow simple exposure to cold. Wheth- 
er or not this exposure acts by preparing a suitable nidus in the 
pleura for the invasion of micro-organisms, or w T hether germ 
infection has nothing to do with this variety, one cannot always 
determine; at all events the existence of an idiopathic pleuritis, lowing- expos- 
following exposure to cold, must be postulated that, for lack of ure to cold 

^ ^ , ' , + . ("Rheumatic 

a better name, may be called rheumatic. pleurisy,") 



332 



PLEURITIS 



Salicylates in 

rheumatic 

pleurisy- 



Sodium sali- 
cylate 
Salol 
Aspirin 
Antipyrin 



Inefiicacy of 
salicylates in 
tuberculous 
form 



Treatment of 
acute pleurisy 



Position in bed 



Diaphoresis 
Dover's powder 
Whisky 
Hot air 



This rheumatic form of pleurisy in contradistinction to all 
other forms is amenable to causal treatment, for, here, the salicyl- 
ate preparations exercise a very apparent effect upon the course 
of the disease. In order to be useful salicylates must be given 
in large doses, either as sodium salicylate in fifteen to twenty 
grain (1 to 1.3 gm.) doses, four or five times a day, or as salol 
(phenyl salicylate) in the same doses, or, best of all, as aspirin 
(acetyl salicylate) in doses of thirty to forty-five grains (2 to 3 
gm.) two or three times a day. Antipyrin, too, in doses of five 
to ten grains (0.3 to 0.6 gm.) given three or four times a day 
in combination with one of the above salicylates is of value in 
some cases. 

This salicylate treatment with or without antipyrin is with- 
out effect in the tuberculous variety of pleurisy and in those 
forms that are due to the invasion of the pleural cavity by other 
bacteria. If there is evidence, therefore, of a tuberculous focus 
or of bacterial infection anywhere in the body; if the onset of 
the disorder is not sudden and does not develop manifestly from 
exposure to cold and chilling of the body surfaces, then the above 
salicylate treatment is not to be employed. For no good can be 
accomplished by it and there is always danger of deranging the 
stomach and bowel and irritating the kidneys when large doses 
of salicylic acid or its derivatives are administered. 

A case of acute pleurisy upon the onset of the first symptoms 
of pain in the chest, dyspnea, cough and fever should be put to 
bed and should be kept there until the temperature is normal. 
The position that the patient occupies in bed should be largely 
left to himself, and it is wrong in these cases to be arbitrary in 
regard to this matter on theoretical grounds. Some patients 
prefer to lie on the unaffected side, especially in the beginning 
of the disorder, because it hurts them very much to lie on the 
sick side. Other patients prefer to rest on the affected side in 
order to aid in immobilizing the chest where it hurts and in- 
stinctively, possibly, by the pressure to reduce the local hyper- 
emia. When much exudate has been poured out the patients 
almost invariably prefer to lie on the affected side, in fact most 
of them cannot lie comfortably on the unaffected side. This is 
due to the fact, self -evidently, that they wish to give the healthy 
side of the chest the greatest freedom for expiratory excursions. 

In the beginning of an attack of pleurisy diaphoretic treat- 
ment is often useful. Medicinally this is best brought about by 
the administration of a ten grain Dover's powder given with a 
glass of hot lemonade to which a tablespoonful of whisky or 
brandy is added, preferably taken in the evening before going 



PLEURITIS 333 

to sleep. In addition the patient may to advantage undergo a 
sweat in the hot air bath. The latter can be arranged as de- 
scribed in the Section on Cardiac Dropsy, page 42, by suspend- 
ing blankets over the patient supported by hoops or a wooden 
framework and conducting heat from an alcohol lamp, placed on 
the floor, through a funnel and rubber tube arrangement under- 
neath the blanket tent. Great care should, of course, be exercised 
that the end of the tube from which the hot air rises does not 
come into immediate contact with the patient 's person, as other- 
wise very disagreeable burns can be produced. If electricity is Electric light 
available in the house, then a chain of incandescent lamps can batl1 
be suspended underneath the blanket tent, or inside of a wooden 
box constructed for the purpose, and degrees of temperature suf- 
ficiently high to cause profuse sweating generated in this way. 
The patient should remain in this hot atmosphere for an hour 
or two with cold cloths or an ice bag applied to the head. When 
the blanket tent is removed the patient's skin should be thor- 
oughly dried with a rough towel and rubbed down with alcohol. 

In cases of pleuritis without exudate immersion in a hot bath Hot bathing in 
is also a very useful procedure to bring about sweating. The y euri& y 
patient should be placed in a bath of from 98° to 100° F'heit 
and instructed to lie perfectly still in the water for fifteen min- 
utes. Here, too, an ice bag or cold cloths should be applied 
to the head in order to prevent reactive hyperemia of the brain. 
While in the bath the patient should be given plenty of water 
to drink. After leaving the bath the skin should be rubbed 
down thoroughly with a rough towel and alcohol. 

While these general measures are being employed every effort 
should be put forward to counteract the hyperemia in the pleura, 
and incidentally to stop the pain and the cough. This can be 
done by local applications to the chest, by strapping the affected 
side with adhesive plaster and by the administration of mor- 
phine. 

Counter-irritation by the application of five or ten leeches Counter-irrita- 
to the skin over the pleuritic area is a very useful means of pro- _ , 
cedure, especially in the beginning of the trouble. The technique wet cupping- 
of leeching has been described in full on page 37. Wet cups 
with or without scarification (see page 39) are also of some 
use as a local counter-irritant. In early stages of pleurisy dry 
cups should, however, never be used as otherwise ecchymosis of 
the underlying pleural membranes may be produced. 

One of the best and simplest counter-irritants is a large mus- Mustar ^ 
tard plaster. This is prepared by mixing equal parts of mus- plaster 
tard and wheat flour and moistening this mixture with warm 



334 



Cold and heat 



Ice bag 
Leiter coil 
Poultices 

Priessnitz 
compresses 



Chloroform 



Iodine 



Anodyne oint- 
ments 



dilute vinegar. This mass is smeared in a thin layer on a piece 
of linen lying on a thick sheet of paper and another piece of 
linen is placed over the mixture. This plaster is laid upon the 
chest with the paper to the outside and left in place until burn- 
ing sets in, it is then removed and the skin treated with olive 
oil. 

Heat and cold per se act as effective counter-irritants to the 
chest wall. Here the sensations of the patient must be our guide, 
some feeling very much more relieved by the application of 
cold to the pleuritic area, others by the application of heat. The 
ice bag or a Leiter coil (page 19) may serve the former purpose; 
poultices made of oatmeal, flaxseed or bread and medicated with 
a few drops of the tincture of opium or belladonna the latter. 

The best effects are produced, however, by cool Priesnitz 
compresses (see index) applied by wringing a linen cloth out of 
water of room temperature, applying it to the affected area and 
covering it with a piece of flannel ; this compress is left in place 
for three or four hours and then renewed. At the end of this 
time the linen will be found to be dry and the underlying skin 
hyperemic, showing that a counter-irritant effect has been pro- 
duced. 

Chloroform may also be used as a counter-irritant, but, on 
account of its blistering properties it is not so pleasant to bear. 
If it is used at all, pure chloroform should be rubbed into the 
skin over the affected area and the treated region covered with 
oiled silk. Iodine, too, may be used as a counter-irritant but is 
not so effective as the other measures enumerated above. 

If the pain is very severe certain anodyne ointments may be 
used. Two very useful ones are : 



V 



Menthol, 
Cocaine muriate, 
Vaseline, 



2.5 

1.0 

60.0 



And 



3 



Chloral hydrate, 

Camphor, 

Vaseline, 



2.00 

0.5 

50.00 



Cantharidal 
plaster 



In those cases in which the pleuritic process remains strictly 
circumscribed for several days, and very early in exudative forms 
of pleuritis, a cantharidal plaster applied once is of value. A 



PLEURITIS 335 

piece of the plaster about six inches square is applied to the 
painful area and left in place six hours. The large blister that 
forms should be opened at once under careful aseptic precautions 
and with sterile instruments. 

If counter-irritation fails to bring about relief, then it may Strapping the 
become necessary to strap the chest with broad strips of adhesive chest 
plaster. The immobilization of the diseased side of the thorax 
that is brought about in this way is always grateful to the patient 
and often very effective in hastening recovery. To strap the 
chest one should proceed as follows : The patient is instructed to 
sit on the edge of the bed or to stand up with the affected side Technique 
away from the physician. The middle of a strip of adhesive plas- 
ter is pressed against the axillary region of the patient while the 
two ends are held by the physician. The patient now presses 
against the strip or is pulled away from the operator by an as- 
sistant and with the chest in an expiratory position the ends of 
the strip are tightly fastened to the middle of the chest and 
back. Two or three strips of this kind may be applied according 
to the extent of the pleuritic affection. 

If the pain is excruciating and the cough very severe, then Morphine for 
hypodermic injections of morphine, one-eighth to one-fourth C0U S n and P am 
grain, repeated if necessary, may have to be given. On account 
of the suggestive effect it is usually best to inject the mor- 
phine directly into the intercostal muscles over the painful 
area. 

In pleurisy, on account of the peculiar distribution and Pain referred 
termination of the intercostal nerves that are being irritated, r e ff ions° & 
it is well to remember that the pain is frequently referred to 
remote regions of the body, so that a patient with a mild pleurisy 
may complain of severe distress in the lumbar region or in the 
anterior abdominal region of either side, thus simulating gall- 
bladder or appendiceal affections, lumbago, renal colic, etc. These 
pains, too, can frequently be stopped by local counter-irritation 
over the affected area in the pleura and by the hypodermic use 
of morphine. 

If active treatment instituted early fails to prevent the forma- Diuresis and 

tion of an exudate, or if the patient is seen for the first time catharsis in 

exudative 
with fluid in the pleural cavity, then in addition to the measures pleurisy 

spoken of above diuresis and catharsis must be stimulated in 
the hope that depletion may aid in the absorption of the exuda- 
tive product. 

The stimulation of diuresis (see also Section on Cardiac Caffein 
Edema, page 42) is of questionable value unless it is combined Theobromin 
with the drink restriction to be discussed presently. Of the 
diuretics that can be employed the caffein group occupies the first 



336 



PLEURITIS 



Diuretin 
Digitalis 
Squills 



Sodium and 

potassium 

acetate 



Epsom, Glau- 
ber, Rochelle 
salts 



Compound in- 
fusion of 
senna 



Jalap 
Elaterium 

Drink re- 
striction 



Thoracentesis 



When to as- 
pirate 



place. Caffein citrate in doses of two to eight grains (0.1 to 0.5 
gm.), or theobromin in eight grain doses (0.5 gm.), or, best of 
all, diuretin, the double salt of sodium theobromin and sodium 
salicylate, in doses of eight to ten grains (0.5 to 0.6" gm.) may all 
be given several times a day. Digitalis and squills, the former as 
the extract of digitalis in doses of one-sixth to one-third (0.01 to 
0.02 gm), the latter in thirty to sixty minims (2 to 4 cc.) doses 
of the syrup of squills, are also useful and can profitably be 
given combined with one of the above mentioned caffein prepa- 
rations. The acetates of sodium and potassium in doses of 
15 to 60 grains (1 to 4 gm.), taken with plenty of hot water 
several times a day are also very useful as diuretics. 

For the purpose of promoting catharsis salines given in con- 
centrated form, preferably in the morning on an empty stomach, 
are by all means the best remedy. A tablespoonful or two of 
Epsom salts, Glauber salts or Rochelle salts by drawing water 
into the intestine by osmosis (see Constipation) produce some 
concentration of the blood and the latter in its turn becom- 
ing more concentrated than the pleuritic exudate abstracts water 
from the pleural cavity. A useful preparation to produce watery 
stools is the Compound Infusion of Senna, containing as a very 
useful ingredient magnesium sulphate. The dose of the remedy 
is two fluid ounces once or twice a day. It is rarely necessary to 
stimulate very active catharsis by the use of jalap or elaterium. 
If these remedies are to be used, two to five grains (0.1 to 0.3 
gm.) of the resin of jalap, or a quarter to one grain (0.016 to 
0.06 gm.) of the trituration of elaterin, may be given. 

The good effects derived from diuresis and catharsis upon 
the absorption of the pleuritic exudate are often enforced by 
the use of a dry diet, i. e., a diet containing the minimum of 
liquids (see Cardiac Dropsy). Here the desire for water may be 
somewhat mitigated by allowing patients to eat ice pills, to chew 
gum or to suck peppermint or menthol lozenges. 

As a last resort in the treatment of pleurisy with effusion 
aspiration of the fluid by thoracentesis must be considered. It 
is often a difficult matter to decide just when to tap the chest. 
Axiomatically one may say that it is always better to aspirate 
too soon than too late, for if the pleuritic exudate is allow r ed to 
remain in the pleura too long the lung is very apt to lose its 
elasticity and its power of expansion, and interstitial pneumonia, 
carnification of the lung and bronchiectasy are quite liable to de- 
velop. Moreover, if the exudate is very large, so that it com- 
presses the lymph stomata in the pleura, absorption of the fluid 
is automatically prevented. 



PLEURITIS 337 

The chief indications for thoracentesis are persistence of the Indications 
exudate at the expiration of three or four weeks and despite the for thora- 
employment of all the measures spoken of above ; then, bilateral 
exudative pleurisy developing rapidly and producing severe 
orthopnea; and, again, severe subjective symptoms due to dis- 
location of the heart with twisting or compression of the large 
vessels at the base of the heart, with pulmonary edema, cerebral 
anemia, peripheral cyanosis, stasis in the abdominal viscera and 
other remote symptoms that can be directly attributed to the 
presence of fluid in the pleural cavity. Finally, tapping of the 
chest may become necessary as a palliative measure in carcino- 
matous and sarcomatous processes involving the pleura. In the 
latter class of cases the fluid is usually hemorrhagic in charac- 
ter and almost invariably reappears after thoracentesis. Here, Thoracentesis 
therefore, one should be conservative in tapping the pleura, for in Hemorrhagic 
the repeated hemorrhages into the pleural cavity are without 
doubt weakening to the patient, so that the removal of the fluid, 
in this class of cases, should be undertaken only when the sub- 
jective symptoms become distressing or directly endanger life. 

The dangers incident to the operation of thoracentesis are 
often grossly exaggerated. It is true that accidents may hap- Dangers of 
pen after withdrawal of fluid from the chest under rigid asepsis, thoracentesis 
or if the fluid is too rapidly removed, especially if due care is 
not exercised in working, notably embolization of cerebral or 
pulmonary arteries, syncope from cerebral anemia, paralysis of 
the heart, pneumothorax, empyema, expectoration of albuminous 
sputum, etc. If the aspiration is carried out carefully and if 
emergency remedies are kept at hand to prevent all possible 
complications about the heart and circulation, then thoracentesis 
is fraught with very slight danger. One should have ready, 
therefore, for such emergencies, analeptics, i. e., a hypodermic Preparation foi 
syringe filled with a ten per cent, solution of camphor in ether thoracentesis 
and a hypodermic of one-thirtieth grain of strychnine sulphate, 
also some smelling salts and a small glass of brandy or whisky. 

Before performing thoracentesis it is always best to give 
the patient a quarter of a grain of morphine, hypodermically, Morphine be- 
to quiet him and to subdue his fear and excitement somewhat, fore thora- 

C6IltGSis 

so that he may co-operate with the operator to the best of his 
ability and also to prevent, as far as that is possible, the cough 
which so frequently follows withdrawal of pleuritic exudate. 

The little field of operation should be rendered thoroughly 
aseptic by scrubbing with soap and water and 1:2000 bichlo- Technique 
ride solution, alcohol and ether. A preliminary puncture should 
always be made with a hypodermic needle in order to ascertain 



338 



Asepsis 



IJhe place of 
puncture 

In the anterior 
axillary line 



At the outer 
angle of the 
scapula 



Danger of 
wounding the 
diaphragm 



Position of 
the patient 



Local anes- 
thesia 



Aspiration of 
the fluid 



with certainty that fluid is present about the spot where it is 
intended to insert the trocar, and also in order to insure the 
absence of a pleuritic adhesion at the point within the area of 
dullness that has been selected for the puncture. 

In selecting the place of puncture two regions are usually 
considered. Either a point in the fifth, sixth or seventh inter- 
space in the anterior axillary line, or a point posteriorly in the 
seventh or eighth interspace near the outer angle of the scapula. 
The former location is the better of the two, for while the bulk 
of the fluid usually accumulates posteriorly after the patient 
has been lying down for days, so that the insertion of the needle 
at the angle of the scapula is most apt to strike the fluid, still 
the posterior intercostal spaces are narrower and the muscles 
of the back are thicker than in the axillary line, so that the 
needle must be pushed in deeper and must ' overcome more re- 
sistence. The fluid, moreover, in the posterior part of the chest 
is apt to contain more abundant flakes of fibrin than in front, 
owing to the fact that the latter sink by gravity; consequently 
posteriorly there is always more risk of occlusion of the needle. 

The puncture should always be made as low down on the 
thorax as possible, care being taken, of course, not to wound 
the diaphragm. The exact location of the diaphragm is, there- 
fore, best determined first on the healthy side and its correspond- 
ing location on the sick side estimated therefrom. 

The patient should be instructed to sit up and to place the 
arm of the affected side on the opposite shoulder as this broad- 
ens the intercostal spaces. Then, as a rule, the needle is in- 
serted quickly into the fifth or sixth interspace, close to the upper 
margin of the rib to avoid injuring an intercostal artery. 

If necessary local anesthesia may be produced by an ether 
spray or a chloride of ethyl spray, and if it is desired to facili- 
tate the entrance of the needle still more and to reduce the pain 
to a minimum, a small incision through the outer integument in 
the anesthetized area may first be made. The entrance of the 
needle into the pleural cavity can readily be determined by a 
certain "give." 

The fluid is now withdrawn either with the aid of a Potain 
or Dieulafoy aspirator, although these complicated apparatuses 
are rarely necessary. The object of using them is to prevent 
the entrance of air into the pleural cavity. This accident can 
very readily be prevented in a simple manner by connecting the 
trocar with a small rubber tube about three or four feet long 
into the end of which a small funnel is inserted; close to the 
needle a clamp compresses the rubber tube. The funnel, tube 



PLEURITIS 339 

and needle are filled with a four per cent, boric acid solution, 
the clamp closed, and, during the insertion of the needle, the 
funnel held high by an assistant. As soon as the needle enters 
the pleural cavity the clamp is removed and the funnel lowered 
into a vessel containing four per cent, boric acid solution. In 
this way the exudate is removed by direct drainage under slight 
negative pressure and there is practically no danger of air en- 
tering the pleural cavity. The rapidity of the out-flow can be 
governed by the clamp. 

After enough of the fluid has been withdrawn the skin is Dressing the 
squeezed tightly about the needle and the latter very rapidly ab- punc ure 
stracted. The little wound is quickly covered with a piece of 
court-plaster or with a small strip of iodoform gauze that is 
glued to the skin with collodion; usually no other dressing is 
required. 

The amount of fluid to be drained off varies according to Quantity of 
individual peculiarities of the case and the reaction of the pa- w ^thdr°awn 
tient. Upon the first appearance of syncope the needle should 
at once be withdrawn and the aspiration of fluid stopped. In 
very large exudates as much as a litre or a litre and a half of 
fluid may be slowly withdrawn with impunity. It will rarely 
be necessary, however, to take away more than 500 cc. 

After the thoracentesis has been performed the patient should After treat- 
remain in bed, hot applications or counter-irritation (see above) 
should be applied to the chest and diuresis and catharsis stimu- 
lated. At the same time in order to promote the expansion of 
the lung the patient should be instructed to take twenty or 
thirty deep, forced inspirations several times a day, raising the 
hands above the head with each expiratory effort or, better still, 
he should perform expiratory movements against pressure, 
either in a pneumatic cabinet or simply by slowly inflating a 
large rubber bag two or three times a day. 

If the contents of the pleura is purulent (empyema), or if Empyema and 
air enters the pleura (pneumothorax) through the chest wall pneumothorax 
after trauma or from perforation of a pulmonary or bronchiec- 
tatic cavity, or from the esophagus, stomach or colon as the 
result of ulcerative perforation, then the treatment becomes sur- 
gical. 

The only treatment of a purulent pleurisy is free incision Treatment of 
and drainage, if necessary with resection of portions of one or purulent 
more ribs. No case should be considered too desperate to at- p euri y 
tempt this operation, as remarkable improvement is generally 
seen in these cases when drainage is established and the pus is 
freely evacuated. As a precautionary measure thoracentesis may 



340 PLEURITIS 

be attempted when the services of a competent surgeon cannot 
at once be secured, or if the patient is in so reduced a condition 
that the evacuation of some of the pus by means of a trocar is 
deemed a conservative preliminary measure instituted in order 
to give the patient more strength and resisting power to with- 
stand the shock of the later operation or, finally, if it is de- 
sired to withdraw large accumulations of pus gradually for fear 
of endangering the patient's life by suddenly changing the 
pressure equilibrium in the thorax. In all these instances thora- 
centesis must, however, always be considered merely as a pal- 
liative and not as a curative measure, notwithstanding the fact 
that very rarely an empyema gets well from simple aspiration 
of pus by tapping. The latter fortunate issue can never be 
counted upon. 

The after-treatment of empyema following evacuation of the 
pus does not differ materially from that employed after thora- 
centesis for simple pleurisy. Special attention should be direct- 
ed toward promoting free expansion of the lungs by forced ex- 
piration exercises against pressure (inflating a rubber bag, blow- 
ing bubbles through a water bottle, breathing in a pneumatic 
chamber, etc.), because in purulent pleurisy in particular there 
is a tendency to the formation of tough adhesions that seriously 
interfere with the expansion and aeration of the lung and hence 
prevent restitution to normal conditions. 
Treatment of In pneumothorax there is usually some fluid in the pleural 

pneumothorax cavity (rarely serous or sero-fibrinous, generally hemorrhagic or 
purulent) ; so that in many of these cases thoracentesis becomes 
necessary. If in simple pneumothorax the intra-thoracic pres- 
sure becomes very high so that the dislocation of the thoracic 
viscera, the excessive compression of the lung with great pain, 
distressing dyspnea, venous congestion about the head and the 
serious interference with the heart's action renders the condi- 
tion of the patient unbearable, then puncture of the chest wall 
may be performed for the purpose of allowing the escape of some 
of the air and rendering the pressure within the pleural sac 
equal to the atmospheric pressure. In valve pneumothorax this 
procedure may have to be repeated at frequent intervals. 

If the pneumothorax develops suddenly from the perforation 
with a sharp pain, profound dyspnea, a weak heart's action, liv- 
idity and symptoms of collapse, then a hypodermic injec- 
tion of one-fourth grain of morphine should be given at once, 
and repeated if necessary. The heart, at the same time, should 
be supported by analeptics (see page 32) ; hot poultices, a mus- 
tard plaster or one of the anodyne preparations enumerated 



PLEURITIS 341 

above must be applied to the chest wall until the most violent 
symptoms have subsided. The subsequent treatment, until 
thoracentesis or thoracotomy are performed, does not differ ma- 
terially from that of any other form of pleurisy. 



CHAPTER VIII. 

DISEASES OF THE DIGESTIVE APPARATUS 

THE STOMACH. 

ACUTE GASTRITIS. 

Acute gastritis, whether due to over-eating or to the inges- 
tion of indigestible articles that irritate and overtax the stom- 
ach, or to alcohol, or to infectious agencies, calls for rest of the 
stomach and prompt evacuation of the offending material. As a 
rule these two postulates are promptly fulfilled by Nature, in- 
asmuch as the patient both manifests a violent aversion for food 
and promptly responds to the ingestion of food by nausea and Evacuation of 
vomiting, or vomits spontaneously. Many cases of acute gastritis * e stomacil 
recover within a few days if not interfered with, especially if Abstinence 
they receive neither food nor medicine. 

During the period of enforced or voluntary fasting most of To control 
the patients complain only of thirst, and this should be appeased thirst 
either by repeatedly washing out the mouth (a procedure 
that is especially agreeable to the patients on account of the 
bad taste and bad breath that usually accompanies acute gas- 
tritis) with some simple mouth wash (see page 260), or by swal- 
lowing ice pills or teaspoonful doses of ice water, ice cold lem- 
onade or orangeade, or very dilute hydrochloric acid. Small 
swallows of ice cold carbonated waters are particularly agree- 
able and soothing to the stomach, because the alkali of the 
water aids in dissolving the mucus and the carbonic acid exer- 
cises a slightly anesthetic effect upon the irritable mucous lining 
of the stomach. 

Should the stomach not spontaneously get rid of its con- 
tents by vomiting, then the evacuation of the stomach contents 
should be artificially promoted either by producing emesis or 
preferably by lavage. 

The ordinary emetics, as ipecac, tartar emetic, etc., should Emetics 
never be given by mouth on account of the irritating effect they Ipecac 
exercise upon the already hyperemic gastric mucosa; besides, ar ar eme 1C 
they take considerable time to produce their effect, and delay 
may be dangerous, especially in children. Sometimes such sim- 
ple measures as drinking lukewarm water, tickling the pharynx Lukewarm 
with the finger, are effective in producing vomiting, especially in water 
patients who vomit easily. Some people, however, vomit with 
great difficulty, or fail to vomit at all with the aid of these sim- 
ple measures, then the stomach contents is not completely evacu- 



344 



ACUTE GASTRITIS 



Apomorphine 



Lavage 



Apparatus to 
be used 



Introduction of 
the stomach 
tube 



Expression 



ated; under such circumstances apomorphine given hypoder- 
mically, in watery solution, in the dose of a twentieth to a tenth 
of a grain (3 to 6 mg.), repeated, if necessary, is a useful 
remedy. 

Best of all, however, is lavage of the stomach either with 
warm water or, better still, with a dilute soda solution con- 
taining one teaspoonful of soda to the quart of water; for the 
soda aids in dissolving the mucus that coats the inner gastric 
walls. 

Many kinds of apparatus have been devised for performing 
lavage of the stomach. It is unnecessary to employ the com- 
plicated systems of funnels, tubes, clamps and glass connections 
that have been described. The latter are chiefly useful in the 
treatment of chronic gastric disorders, and for use by the patient 
himself, or by the inventor of the device. 

For ordinary use at home a simple stomach tube and a 
glass funnel, or a stomach tube with an aspirating bulb, are the 
most convenient and the simplest to employ. If the funnel is 
used, the stomach contents is removed by siphonage ; if the bulb 
is used, by aspiration. The tube should be smooth and soft. 
Stiff tubes with longitudinal ridges should not be used. 

The introduction of the stomach tube should never be at- 
tended with much difficulty. Inasmuch as it is usually more diffi- 
cult for the physician and less agreeable to the patient to have 
the stomach tube passed in the recumbent than in the upright 
position, it is best, especially if lavage of the stomach is being 
performed for the first time, to have the patient sit up opposite to 
the physician with the head slightly bent forward. Before in- 
troducing the stomach tube the manipulation that it is intended 
to perform should be carefully explained to the patient and as- 
surance should be given that the tube will be promptly with- 
drawn if it does not slide down easily, or if it produces gagging 
or choking. In excitable or nervous subjects the physician 
should continuously speak to the patient, encourage him to 
breathe deeply and to keep his mouth open and to perform 
swallowing movements until the tube enters the stomach. The 
tube should be moistened with water (not with oil, vaseline or 
glycerin) and advanced to the pharyngeal wall; the patient 
should then be told to perform swallowing movements, with the 
head bent slightly forward and to continue swallowing while 
the physician pushes the tube down until it reaches the stomach. 

The patient may now attempt to express the stomach con- 
tents by retracting the abdominal muscles and straining; in 
this way a large proportion of the offending material may often 
be evacuated. If this manipulation does not bring out any of 



ACUTE GASTRITIS 345 

the stomach contents, then a large funnel holding about 500 
cc. should be inserted into the free end of the stomach tube 
and held about two feet above the patient's mouth and a dilute 
soda solution (see above) poured into it. As soon as most of the 
fluid has passed down, the funnel should be lowered below the 
level of the stomach and the contents removed in this way by 
siphonage. This manipulation should be repeated several times 
until the wash water comes out clear. If the patient shows con- syphonage 
siderable tolerance for the stomach tube, then it is well to have 
him lie down with the tube in place and to perform lavage again 
in the recumbent position. It will often be found that in this 
way considerable material will be removed from the stomach, Lavage in re- 
even if the wash water came out quite clear while the patient £JJJ£ en posl " 
was sitting up. In order to avoid retention of the wash water 
in the stomach it is best to catch the water returning from the 
stomach in a graduated vessel and to measure carefully the 
amount of water poured in and the amount recovered from the 
stomach. 

If the water is poured into the funnel too quickly a vortex is Accidents to be 
often formed and, in this way, considerable air is sucked into av01 e 
the stomach; when this occurs the funnel should be held in a 
slanting position at once, and the aspiration of air will stop. 
Quite frequently when the patient begins to perform vomiting 
movements the wash water pours out alongside the tube ; this 
is due either to pouring the water in too quickly or under 
too great pressure; the remedy, therefore, is to pour the water 
more slowly and to lower the funnel. If the tube has been 
pushed in a little too far so that it touches the sensitive mucosa 
at the fundus, then vomiting and retching may also occur; here 
withdrawal of the tube an inch or two will frequently stop the 
patient's distress and the pouring out of water through the 
mouth. 

The tube should be withdrawn with some water still in the Withdrawing 
funnel. It is always dangerous to let all the water run out of 
the funnel as, in this way, considerable air may be pumped into 
the stomach upon a second washing or in withdrawing the tube 
some of the mucosa may be pulled off. In removing the tube, 
therefore, it should be withdrawn with the water still flowing 
until its lowest point is well above the cardia. As soon as the 
tip of the tube is out of the stomach, the tube should be com- 
pressed below the funnel and drawn out quickly. 

Many of the accidents and disagreeable complications spoken Aspiration 
of above can be avoided by using an aspirating bulb instead of 
a funnel. The tube is inserted as described above, the aspir- 



346 



ACUTE GASTRITIS 



Laxatives 



Castor oil 
Calomel 



Diarrhea 



Constipation 



Bowel irriga- 
tion 



Pain 



Priessnitz 
compress 



ating bulb compressed and attached to the open end of the stom- 
ach tube and then allowed to expand, and in this simple way the 
stomach contents aspirated. In order to perform lavage with. 
the aspirating bulb the bulb is filled with water, the water 
pressed into the stomach and removed immediately by allowing 
the bulb to expand; the tube should be withdrawn with the 
bulb expanded. 

Evacuation of the stomach contents usually brings prompt 
relief. Often spoiled or fermenting food has passed on into the 
bowel before the stomach contents is evacuated, then empty- 
ing of the bowel may also become necessary. This is best 
brought about by the use of castor oil in tablespoonful doses; 
for the latter (aside from frequently producing nausea and 
thereby emesis) exercises a rapid purgative effect. Calomel r 
too, is a useful remedy in these cases, for it acts as a cholagogue, 
a rapid evacuant and an antiseptic. It should be given in doses- 
of two to three grains (0.13 to 0.2 gm.), or in several doses of 
a half grain (0.03 gm.) every hour for four or five doses, fol- 
lowed within a few hours after the administration of the last 
dose by a tablespoonful of castor oil or a saline laxative (see 
also page 414). 

This practice usually stops the diarrhea that is apt to super- 
vene if evacuation of the irritating bowel contents is not 
promptly brought about. It also successfully counteracts the 
obstinate constipation that sometimes complicates acute gas- 
tritis. It is always bad practice to attempt to check the diar- 
rhea by the use of opiates, tannic acid or other anti-diarrheie 
remedies before complete evacuation of the putrid bowel contents 
has been promoted. 

In addition to producing evacuation of the bowel by the ad- 
ministration of castor oil or calomel by mouth, bowel irrigation 
with oil or with glycerin in water or soapsuds in water is very 
useful. By cleansing the lower bowel the colicky pains are 
often relieved, for the latter are chiefly produced by the in- 
creased peristaltic movements of the small intestine and are 
rendered more severe if an obstacle to the evacuation of the 
bowel contents is offered by impaction of the colon with solid 
fecal material. 

The pain and the distress in the epigastric region usually 
disappear within a day or two if the above measures are adopted. 
If the pain persists or is very severe, a Priessnitz compress ap- 
plied to the epigastrium generally acts as an effective counter- 
irritant and analgesic. Such a compress is applied by laying 



ACUTE GASTRITIS 347 

a linen cloth, wrung out of cool water, upon the epigastrium and 
covering it with a piece of flannel. This application should be 
repeated every two or three hours. Sometimes a hot water bag Heat 
over the stomach or a thermophore (see index) are grateful 
to the patient. In extreme cases with much pain and very 
persistent vomiting a hypodermic of an eighth of a grain of 
morphine with a two-hundredth of atropine, or opium with 
belladonna in suppository of the extract each y 2 gr., may have Morphine 
to be given; or if there is very much hyperesthesia of the gas- Belladonna 
trie mucosa, cocaine as described on page 19 may be adminis- Cocame 
tered. 

After a period of starvation lasting for twenty-four to forty- Diet 
eight hours some food should, by all means, be administered. 
The diet should at first be liquid and cold and should be given 
in small quantities, beginning with teaspoonful doses of cold 
milk or thin gruels made with water or milk, possibly with an 
egg stirred in. Later, as the patient recovers, easily digestible 
foods should be administered in gradually increasing quantities. 

THE DIGESTIBILITY OF FOODS 

This question of digestibilit}' is a difficult one. As a rule 
the criterion of digestibility is considered to be the length of 
time that an article of food remains in the stomach, and a num- 
ber of tables have been arranged by different clinicians, giving 
a scale of digestibility based on this standard. The following, 
by Pentzoldt, is one of the most reliable, and has the advantage, 
moreover, of giving the quantities of the different foods : 

The stomach normally empties itself of the following articles 
in the time named : 

SCALE OF DIGESTIBILITY. 

Within one or two hours. 
100-200 cc. water, pure. 
200 cc. water, carbonated. 
200 cc. tea. 
200 cc. coffee. 
200 cc. cocoa. 
200 cc. beer. 
200 cc. light wine. 
100-200 cc. milk, boiled. 
200 cc. meat broth without additions. 
100 gm. eggs. 

Within two or three hours. 
200 cc. coffee with cream. 
200 cc. cocoa with milk. 



348 ACUTE GASTRITIS 

200 cc. malaga wine. 

300-500 water. 

300-500 beer. 

300-500 milk, boiled. 

100 gm. eggs, raw, hard boiled, or as omelette. 

100 gm. beef, raw sausage. 

250 gm. calf's brains, boiled. 

250 gm. sweetbreads, boiled. 

72 gm. oysters, raw. 
200 gm. carp, boiled. 
200 gm. pike, boiled. 
200 gm. codfish, boiled. 
150 gm. cauliflower, boiled. 
150 gm. cauliflower, salad. 
150 gm. potaoes, boiled. 
150 gm. mashed potatoes. 
150 gm. stewed cherries. 
150 gm. raw cherries. 

70 gm. white bread, fresh and stale, dry or with tea. 

70 gm. zwieback, fresh and stale, dry or with tea. 

Within three or four hours. 
230 gm. young boiled chicken. 
220-260 gm. squab, boiled. 
195 gm. squab, roast. 
230 gm. partridge, roast. 
220-230 gm. young chicken, roast. 
250 gm. beef, raw, boiled (lean). 
250 gm. calf's feet, boiled. 
160 gm. ham, raw and boiled. 
100 gm. veal, warm and cold (lean). 
100 gm. beefsteak, broiled, cold and warm. 
100 gm. beefsteak, raw, scraped. 
100 gm, roast beef. 
72 gm. caviar, salt. 
150 gm. brown bread. 
150 gm. Graham bread. 
150 gm. white bread. 
100-150 gm. Albert biscuits. 
150 gm. potatoes, vegetable. 
150 gm. rice, boiled. 
150 gm. carrots, boiled. 
150 gm. spinach, boiled. 
150 gm. cucumber salad. 



ACUTE GASTRITIS 349 

150 gm. radishes, raw. 
150 gm. apples. 

Within four or five hours. 

210 gm. squab, broiled. 

250 gm. fillet of beef, roast. 

250 gm. beefsteak, broiled. 

250 gm. beef tongue, smoked. 

250 gm. rabbit, roast. 

240 gm. partridge, roast. 

250 gm. goose, roast. 

280 gm. duck, roast. 

200 gm. salt herring. 

150 gm. lentil puree. 

150 gm. string beans, boiled. 

The length of time during which an article of food remains Definition of 
in the stomach is not, however, the only measure of its digesti- 1 ^ estl lllt f 
bility, especially in pathological cases; for, broadly speaking, 
an article of food may be considered digestible, first, if it pro- 
duces no disagreeable subjective symptoms; second, if it does 
not over-tax either the motor or the secretory powers of the 
stomach. The element of idiosyncrasy also enters into the equa- 
tion here ; for an article may be very well digested in the stom- 
ach but not be well borne by the patient or, on the other hand, it 
may be well borne, i. e., cause no subjective symptoms of dis- 
tress and still may leave the stomach in a practically undigested 
form to undergo, finally, disassimilation in the intestine. In 
either case the article must, insofar as the stomach is concerned, 
be considered indigestible, for it fails to meet the prime require- 
ments of a digestible article, i. e., neither to over-tax the motor, 
the secretory or the sensory function of the diseased organ. In 
pathological cases where the perversions of these three func- 
tions are frequently associated this applies with particular force, 
as will be shown later when discussing chronic disorders of the 
stomach and the functional perversions of the organ. 

In this place, however, some general considerations in re- 
gard to the utility of different foods in stomach disorders, i. e., Dig-estibilitv 
their digestibility in a broader sense, may be inserted. of meats 

The digestibility of meats depends upon their origin, upon 
the amount of fat they contain and their mode of preparation. 
The most digestible varieties of meat are poultry, especially 
chicken and squab; less digestible are duck and goose. Yeal, 
if sufficiently aged (see below) and properly prepared, comes 



350 



ACUTE GASTRITIS 



The fat of 
meat 



Haw meat and 
cooked meat 



Methods of 
cooking" meat 



Smoked, cured 
corned meats 



Fresh and 
"hung" meat 



"Hig\h" meats 



next in the stage of digestibility, then fish with the exception of 
the fat varieties like trout, mackerel, pickerel and salmon; less 
digestible than the above are beef, pork and mutton. 

The more fat meat contains the less digestible it is; for fat 
is not at all digestible by the juices of the stomach and as it sur- 
rounds the muscle fibers it protects them from the action of the 
gastric juices, so that a large proportion of the albuminous con- 
stituents of fat meat pass from the stomach into the intestine 
practically undigested. 

Raw meat is more digestible than meat cooked in any way, 
especially if it is chopped or scraped, for in this manner the 
connective tissue fibers are torn and macerated and free access 
to the muscle tissue is given to the gastric juice. Rare meats 
are always more easily digested than meats that are well done. 

Boiled, stewed or roast meats are about equally digestible; 
their nutritive value, however, varies according to the method 
of cooking. If the meat is placed at once into boiling water, 
the albumens on the surface are promptly coagulated, so that 
the nutritive ingredients of the meat are retained. If it is 
intended to make stew, i. e., to extract the nutritive ingredients, 
then the meat should, of course, be placed into cold water which 
is gradually heated to the boiling point. The same principle 
obtains in roasting meat; it remains most nutritious if it is 
exposed at once to great heat, for in this way the coagulate that 
forms on the outside prevents the nutritive juices from running 
out into the pan. 

Smoked, cured and corned meats are less digestible than raw 
or cooked meats, because they contain creosote and similar 
products that are generated during the process of smoking and 
curing, and these creosote preparations materially interfere with 
digestion. The large amount of salt contained in salt meats and 
fish is also detrimental, so that the digestibility of the latter 
foods must be estimated as low. 

Meat in order to be digestible should not be too fresh, for, 
if eaten within a few hours after the animal is killed, i. e., while 
the muscle tissue is still in a state of rigor mortis, the coagulated 
myosin renders the meat fibers difficult of digestion. After 
hanging for a time lactic acid forms and softens the connective 
tissues while bacteria cause dissolution of the myosin coagulate. 
The meat should, of course, not hang too long nor in too warm 
a temperature, as otherwise putrefactive processes may set in 
with the formation of ptomaines. ''High" game and poultry, 
therefore, are very detrimental in any stomach disease. As poul- 



ACUTE GASTRITIS 351 

try is eaten almost immediately after it is killed, i. e., before 
myosin coagulation occurs, both the above difficulties are usually 
obviated. 

Meat broths contain salts, extractives, kreatinin, gelatin, a Broths 
little albumen and peptones, hardly any fat, and water; their 
nutritive value, therefore, is very small. They act chiefly as 
stimulants to the flow of gastric juice and, through the extrac- 
tives they contain, as stimulants to the nervous system and the 
circulation. Unless contra-indicated by conditions of the 
stomach in which it is desired not to dilute the gastric juice or 
to over-tax the weak gastric musculature by the ingestion of 
much fluid, meat broths fulfill a useful purpose. 

So-called peptones and different predigested foods contain Albumoses and 
albumoses; the latter are more easily assimilable than native peptones 
albumen, and they can replace albumens to some extent. In- 
asmuch, therefore, as they are nutritious and non-irritating to 
the stomach wall they serve a useful purpose, especially in gas- 
tric catarrh. Their taste unfortunately is disagreeable to many 
people and occasionally they produce diarrhea. 

Gelatinous foods, in small quantities, are a very useful ad- Gelatin 
dition to the diet in the form of gelatin, aspic, meat jellies, 
calves' head, etc. ; they are non-irritating to the stomach, but also 
occasionally produce diarrhea. 

The digestibility of eggs depends exclusively upon their mode Eggs 
of preparation. Soft boiled eggs and eggs stirred in soups or 
poached very soft are the most digestible of all ; raw eggs, fried 
eggs and hard boiled eggs the least digestible. The white of 
egg is more digestible than the yolk on account of the fat that 
the latter contains. A very digestible and very nutritious prepa- 
ration is a watery solution of egg albumen with a little salt. 

Milk constitutes a very nourishing, digestible and non-irri- Milk 
tating food, so that it should occupy a large place in the dietary 
of stomach cases. Some people possess a distinct idiosyncrasy 
against milk, manifesting not only a thorough distaste for it 
in any form, but also an inability to properly digest it. The 
latter difficulty may occasionaly be overcome by the addition of 
lime water, soda, magnesia or brandy, all ingredients that are 
intended chiefly to change the character of the curds that form 
in the stomach. If milk cannot be taken, buttermilk, kephyr, 
kumyss or solutions of condensed milk serve an equally useful 
purpose. There is no difference in digestibility between raw or 
boiled milk. 

Inasmuch as milk, as shown in a previous section (see page Gruels 
208) cannot fulfill the caloric requirements of an individual if 



352 



ACUTE GASTRITIS 



Vegetables 



Fruits 



Nut emulsions 



Bread stuffs 



given as the exclusive article of diet, it is best to add to it cer- 
tain cereals, as wheat, barley or oatmeal flour, rice, sago, tapioca, 
or one of the many dextrinized foods that are on the market. 
The addition of these various substances in no way renders the 
milk less digestible and materially adds to its nutritive value, 
so that the patient can subsist for a long time upon gruels made 
with milk in this way. 

Among vegetables, potatoes and other vegetables growing 
under ground and those growing in pods are most nutritious and 
most digestible, especially if served boiled in water or, best of all, 
mashed or as purees. Leafy vegetables are not very nutritious, 
contain abundant cellulose, which is not at all digestible, and 
frequently acids, which may be harmful in diseases of the stom- 
ach. Salads, therefore, prepared with oil, vinegar and spices are 
to be especially avoided in stomach diseases : for the character of 
the leaves from which the salads are made, the fat, the acid and 
the spices all render salad harmful. Very digestible and nutri- 
tious vegetables are cauliflower, asparagus (especially the heads), 
spinach and string beans. 

Fruits should be given sparingly in stomach diseases for they 
contain abundant cellulose, free acids and much sugar and are 
very commonly contaminated with bacteria. The least harmful 
fruits are apples and pears, better given stewed than raw. 
Grapes, too, are very useful. Berries on account of the seeds and 
acids they contain, cherries, plums and peaches on account of 
the acids and the abundant cellulose are not very good. Nuts 
are very indigestible. A useful preparation of nuts, however, 
is so-called nut-milk made from ground almonds or other nuts 
mixed with four or five parts of water and two or three parts 
of milk. Such nut emulsions are very soothing to the stomach 
and are also nourishing on account of the albumens, fats and 
sugar they contain. 

Of bread stuffs the best are toast, crackers and zwieback. 
Stale bread is always better digested than fresh bread, especially 
hot bread. The crust of bread is by far preferable to the soft 
portions ; for the former is better dextrinized and hence partially 
predigested and, moreover, requires more thorough mastication, 
hence preliminary dextrinization m the mouth, than the soft 
part of the bread. Breads made of coarse flours require a very 
active gastric juice and should never be given if the gastric 
function is weak; they have a distinct place, however, in the 
treatment of some gastro-intestinal diseases, especially where it is 
desired to stimulate peristalsis of the intestine. The so-called 
diabetic breads described on page 126 are digestible and nutri- 



ACUTE GASTRITIS 353 

tious without being irritating to the stomach, hence they are 
very useful in stomach disorders. 

Sugar is introduced either in the form of cane sugar in Sugar 
ordinary table sugar and some vegetables; or as dextrose or 
levulose in grapes, honey and certain fruits; and as lactose in 
milk. Inasmuch as dextrose and levulose are absorbed directly 
and rapidly, whereas cane sugar must first be split (inverted) 
into dextrose and levulose before it can be absorbed, it is clear 
that the administration of the former sugars is more rational 
than that of cane sugar ; for the latter is forced to remain in the 
stomach and upper portion of the bowel longer than dextrose or 
levulose; hence fermentation is more apt to occur with gaseous 
distention of the stomach and bowel if cane sugar is given than 
if sugar is administered in the form of dextrose or levulose. It 
has been established, moreover, that cane sugar retards the 
digestion of the albumens and fats to some extent. In stomach 
diseases, therefore, cane sugar should be given sparingly and 
the demands of the patient for sweet foods should largely be 
satisfied by the administration of honey or dextrose. 

The digestibility of fats is approximately proportionate to Fats 
their melting point ; the lower the melting point the more digest- 
ible they are as a rule; thus vegetable oils and the milk fats, i. e., 
butter and cream and milk, are by far more digestible than 
animal fats. The digestibility of the latter, moreover, is im- 
paired by the fact that the fat is enclosed in a tough cell 
membrane. 

Of beverages, water in large quantities should always be Beverages 
avoided in stomach diseases, for it taxes the motor power of the 
stomach, retards digestion and dilutes the gastric juice. Suf- 
ferers from stomach disorders should, therefore, refrain from 
drinking much water immediately before, during or after meals. 

The use of coffee in stomach cases must be largely governed Coffee 
by the reaction of the patient. Tea and coffee, per sc, exercise Tea 
no effect upon gastric digestion, itself. In some persons they act 
upon the nervous apparatus, producing certain symptoms about 
the higher cerebral centers and also somewhat stimulating per- 
istalsis. The prejudice against coffee and tea in stomach dis- 
eases is largely exaggerated. If a choice is to be made between 
the two, tea, empirically, is probably less harmful than coffee. 
It is generally a superfluous restriction to forbid the use of small 
quantities of coffee, especially for breakfast, to people who have 
been used to this beverage all their lives. 

The use of small quantities of alcoholic beverages is generally Alcohol 
useful in stomach disorders. That alcohol in anv form should 



354 



CHRONIC GASTRITIS 



Brandy, liq- 
ueurs, Claret, 
Moselle 



Cider 
Beer 



Champagne 



Smoking 



be avoided in acute gastritis need hardly be emphasized, but in 
more chronic varieties of stomach disorders, especially in certain 
functional disturbances, small quantities of alcohol act as a 
stimulus to the motor power and the secretion of the stomach, 
increase the appetite and materially aid in the digestion of fats 
by promoting the evacuation of the latter from the stomach. It 
is true that alcohol precipitates pepsin, but this disadvantage is 
more than overbalanced by the advantages enumerated above. 
Most cases of chronic stomach trouble are benefited by the 'use 
of a little brandy, a liqueur or Sherry after meals or by drinking 
a glass or two of light Claret, Burgundy or Moselle wine during 
their meals. 

Cider on account of the large quantity of acid it contains is 
not so useful a beverage. Beer should be forbidden, for it con- 
tains abundant carbonic acid gas which distends the stomach, 
especially as it is always taken in relatively large quantities, 
hence violates the principle of restricting the liquid intake 
during and before meals. Beer, moreover, unless pasteurized, 
contains yeast cells which are very apt to set up fermentative 
processes in the stomach and bowel. Small quantities of cham- 
pagne are useful both on account of the alcohol and the carbon 
dioxide they contain. Large quantities should, however, never 
be given because of the danger of distending the stomach from 
the rapid evolution of gas. 

Smoking, finally, should never be permitted in acute gastric 
disorders. In other gastric troubles it should never be allowed 
when the stomach is empty, for it undoubtedly reduces the 
appetite. A cigar or two a day, however, especially in men who 
have been accustomed to the use of tobacco all their lives, in- 
dulged after meals can do no harm and it is a cruel and unnec- 
essary restriction to dogmatically forbid the use of tobacco in 
every case of stomach disorder. 



CHRONIC GASTRITIS. 

Causes Chronic gastritis may develop consecutively to a number of 

primary disorders about the heart, the liver, the kidneys and 
the lungs. In all these conditions disturbances of the circulation 
leading to venous stasis in the stomach or portal stasis are re- 
sponsible for the gastric catarrhal symptoms. In many meta- 
bolic disorders, in severe anemia and leukemia, chronic gastritis 
is an important phenomenon. Chronic gastric catarrh may also 
accompany certain organic diseases of the stomach like car- 
cinoma, ulcer, ectasy. 



CHRONIC GASTRITIS 355 

Chronic gastritis does not invariably accompany these differ- 
ent diseases, hence the existence of special factors must be postu- 
lated in many cases that determine the development of catarrh. 
Chief among the latter are any of the agencies that have been en- 
umerated in the preceding section as producing acute gastritis, 
especially if these agencies remain operative for a long time. In- 
discretions in diet, that is, eating the wrong food or too much food, 
fast eating, failure to properly masticate the food, the abuse of 
alcohol, the excessive use of spices, of hot foods and of medi- 
cines, chiefly purgatives, can all cause chronic gastric catarrh. 
All these factors may also produce chronic gastritis without the 
presence of any of the general disorders mentioned above, either 
by causing acute gastritis, which is neglected, or which fre- 
quently recurs and finally becomes chronic, or by producing 
slow, gradual involvement of the gastric mucosa, so that chronic 
gastritis insidiously develops. 

In instituting causal and prophylactic treatment in chronic Causal and 
gastritis all these elements must be considered. Any circula- treatment 1C 
tory disorder that may be present must be corrected, if possible, 
by the use of all those measures that can counteract venous 
stasis in the general circulation and chiefly in the portal area. 
The renal, pulmonary, metabolic, hematic disorders that may be 
present must be carefully treated as described in other sections. 

In chronic gastric catarrh two elements predominate, there 
is first an excessive secretion of mucus and second, a perversion 
of the gastric secretion generally manifesting itself by a deficient 
outpouring of digestive ferments and of hydrochloric acid; (in 
rare cases, however, there may be hyperchlorhydria). The food 
introduced into the stomach owing to these abnormal conditions 
fails to undergo proper disassimilation and hence stagnates, 
especially as the chronic inflammation of the stomach wall often 
leads to weakening and atony of the gastric musculature ; conse- 
quently abnormal fermentation of the gastric contents com- 
monly occurs and the condition is further aggravated by the 
formation of irritating poisonous acids, ptomaines and gases. 

The indications for treatment are to remove the mucus; to General indi- 

correct the perversion of secretion ; to administer a diet that catl ° ns f J r 

r treatment 

spares the gastric function and that can be promptly propelled 

onward into the intestine; to remove the irritating products of 

fermentation ; and, last of all, to stop the fermentative processes, 

so far as that can be accomplished, by the use of appropriate 

measures. 

In order to remove the mucus, lavage is the sovereign remedy. Lavage 

In chronic gastritis the stomach should be washed persistently. 



356 



CHRONIC GASTRITIS 



Lavage in the 
morning 



Lavage in the 
afternoon 



Lavage in the 
evening 



Irrigation 
fluids 



Alkalies 
Salt 



Antiseptics 
Potassium per- 
manganate, 
salicylic acid, 
thymol, hydro- 
chloric acid 



In mild cases, lavage in the morning before breakfast is usually 
sufficient ; at this time any stagnating contents that may have re- 
mained in the stomach overnight has become decomposed and 
softened, so that it is easily removed with the stomach washings. 
At all events at this time any food material that may still be 
present in the stomach no longer possesses much nutritive value, 
so that it is best removed. It is, moreover, a precarious procedure 
to introduce fresh food into a stomach that contains ferment- 
ing and decomposed material from the previous day (see also 
page 388). 

In some cases of gastric catarrh in which the motor power of 
the stomach is sufficiently good to cause the evacuation of all the 
stomach contents during the night, it may be better to perform 
lavage six or seven hours after the main midday meal, especially 
as these patients suffer the greatest distress and discomfort at 
such time. In this way much of the mucus is removed and the 
stomach is relieved of labor that it is manifestly unable to per- 
form, for, normally, the stomach should be empty at this time. 
If the stomach contents is removed late in the afternoon, then 
the patient should receive a very light evening meal. 

In another variety of cases the patients complain of the 
greatest distress at night; this occurs particularly if the heaviest 
meal is eaten in the evening and the patients go to bed three or 
four hours after their dinner. Here distention of the stomach 
with gases, sour eructations, epigastric pain, awaken the patients 
in the night and seriously interfere with sleep and hence general 
nutrition. In such cases it is best to perform lavage of the stom- 
ach just before the patients retire for the night. 

In many cases, finally, it may be necessary to perform lavage 
both in the morning on rising and six hours after the main meal, 
or in the morning and on retiring. 

If there is only little mucus, simple water of body temperature 
may be used. In some cases, however, it is advantageous to use 
an alkaline or saline solution containing two teaspoonfuls of sodi- 
um carbonate to a litre, or five teaspoonfuls of lime water to a 
litre, or ten grammes of common salt to a litre, or a teaspoonful 
of a mixture of two parts of common salt and one part of sodium 
carbonate to the litre. The alkalines aid materially in dissolving 
the mucus and also in neutralizing the acids that are formed by 
fermentation. 

The addition of antiseptic remedies to the wash water can do 
no harm. Very useful solutions are potassium permanganate, 
0.1 to 2000; salicylic acid, 1:1000; thymol, 1:2000; hydrochloric 
acid, five drops to 1000. 



Mineral waters 



CHRONIC GASTRITIS 357 

The evacuation of the stomach mucus can be further aided by 
forcing the water into the stomach under considerable pressure, 
i. e., either by holding the funnel high above the mouth, or better 
still, by using the stomach tube and aspirating bulb and exercis- 
ing considerable pressure upon the bulb when the water is forced 
into the stomach. Lavage should be continued until the wash Technique of 
water comes out quite clear. In some cases it will be necessary lavage in 
to wash the stomach out with the patient sitting erect and also tritis 110 S&S 
lying down. In chronic gastritis, in which the patients soon be- 
come accustomed to the use of the stomach tube, there is no diffi- 
culty in keeping the tube in place while the patient changes his 
position. 

There are distinct contra-indications to the use of the stomach Contra-indica- 

tube, namely, advanced arterio-sclerosis, heart lesions in stages tions to us e of 

o -. , ,. it- • stomach tube 

oi pronounced decompensation, esophageal varices, aneurism, 

angina pectoris and great hyper-excitability or pronounced gen- 
eral debility of the patient. If any of the above named condi- 
tions exist, so that the use of lavage must be reluctantly aban- 
doned, then mineral waters must take the place of gastric lavage. 

Mineral waters may, of course, also be used in combination 
with lavage in any subject. They act very much like lavage, 
with the difference that the mucus and the fermenting material 
that they dissolve is washed into the intestine instead of being 
removed by the mouth. The use of mineral waters is, therefore, 
by no means so valuable nor are the results from their employ- 
ment to be compared with those obtained from washing out the 
stomach. If there is much motor insufficiency, the ingestion of 
abundant water is, moreover, distinctly contra-indicated. Much 
harm can be done from the routine use of so-called water cures. 

Part of the benefit accruing to stomach cases from the use of ;R esort treat- 
the various mineral waters must be attributed more to the life at ment 
the resorts in which these waters are taken than to any of the 
healing properties of the waters themselves; for sufferers from 
digestive disorders who go to a watering place lead a life of great 
regularity among pleasant surroundings, free from the worry 
and routine of their daily existence; they are careful in their 
diet and are, above all, under the supervision of physicians who 
are especially skilled in the treatment of this class of diseases. 

In many of the resorts routine regulations are given the pa- Dangers of 
tients in regard to their diet, and they are told, often on printed rou tine in re- 
slips, what to eat and what not to eat during their water cure. 
Broadly speaking these restrictions are all theoretically con- 
structed and no special dietetic restrictions need, as a rule, be 
observed when the different waters are taken that would not be 



358 



CHRONIC GASTRITIS 



Alkaline 
waters 



Saline waters 



Sulpho-saline 
waters 



Lime waters 



Carbonated 
waters 



Temperature 
of the waters 



observed if no water cure were being instituted. The chief dan- 
ger lies in the drinking of too much water and in drinking large 
quantities of water too rapidly, most patients imagining that 
if a little of the waters will do them good, a great deal must do 
them more good; and they are generally encouraged in this be- 
lief by the attendants and occasionally by the physicians in these 
resorts. 

The chemical ingredients of the different waters determine 
their use in different conditions. Alkaline waters aid in dissolv- 
ing the mucus, in combining the organic acids that are formed 
by fermentation in the stomach and by increasing intestinal 
peristalsis. They, as well as the alkaline saline waters, are espe- 
cially useful in atonic and secondary catarrh of the stomach. 
Alkaline waters alone have their particular field of application 
in chronic hyper-acidity with catarrh. Saline waters, which 
should never contain more than ten per cent, of sodium chlor- 
ide, stimulate the formation of hydrochloric acid and of the di- 
gestive ferments, and also excite the motor power of the stomach 
and to some extent the appetite. They are especially useful, 
therefore, in cases with hypo-secretion and slight motor insuf- 
ficiency. 

Waters containing Glauber salts, and sulphur waters, as well 
as the bitter waters, are useful, particularly when gastric catarrh 
is accompanied by obstinate constipation and abdominal ple- 
thora. As they are somewhat irritating to the stomach, their use 
is limited in gastric disorders. 

Lime waters act like the alkaline waters, i. e., they are useful 
on account of their antacid and mucus dissolving properties. 

The carbonic acid that many waters contain causes prompt 
belching of carbonic acid gas and this occasionally aids materi- 
ally in the expulsion of fermentative gases that are accumulat- 
ing in the stomach. The carbonic acid gas, moreover, acts as an 
anesthetic to the gastric mucosa in painful complications of the 
stomach, slightly stimulates the appetite and increases intestinal 
peristalsis. Carbonated waters should, of course, never be used 
in motor insufficiency and gastric atony, for here, precisely, dis- 
tention of the stomach is to be avoided. The same applies to 
cardiac or respiratory diseases in which the stomach function is 
perverted, for here, too, distention of the stomach and bowel, by 
interfering with the respiratory excursions of the diaphragm, 
and hence by imposing more labor upon the right heart, is to be 
avoided. 

The following rule may be formulated in regard to the tem- 
perature at which these different mineral waters should be taken : 



CHRONIC GASTRITIS 359 

If there is some motor insufficiency with decreased secretion of 
gastric juice and a tendency to constipation, then the mineral wa- 
ters should be taken cold. If the gastric and intestinal mucosa 
is very irritable, and if there is a tendency to diarrhea, then 
warm or hot mineral waters are more grateful to the patient and 
probably more useful. 

No fixed directions can be given in regard to the diet in cases Diet 
of chronic gastritis. In each case repeated analyses of the stom- 
ach function should be made and the diet arranged according to 
the secretory and motor powers of the stomach, as described in 
subsequent sections. At the same time, in view of the fact that 
chronic gastritis is usually a disorder of long duration, every 
endeavor should be put forward to maintain full nutrition of 
the patient by supplying sufficient calories in the food. In most 
cases of chronic gastritis the presence of mucus (which covers the 
gastric walls and becomes intimately mixed with the food, thus 
preventing to some extent the outpouring of gastric juice and its 
mixture with the food) as well as the reduction of the hydro- 
chloric acid, will have to be considered. Hence the food should 
be finely divided, thoroughly masticated and insalivated in order 
to impose as little labor as possible upon the stomach digestion 
and to facilitate the prompt removal of the food onward into the 
intestine. 

The carbohydrates in the diet should preponderate, espe- Proportion of 

carbohydrates, 
cially if there is any motor insufficiency ; for they undergo diges- fats, proteid 

tion almost exclusively in the intestine. The same applies to fats 
and the latter should be supplied in the form of digestible varie- 
ties of fats, i. e., milk fat or vegetable oils. Enough proteid 
should be supplied in the form of digestible meats (see page 347) 
to meet the nitrogen requirements of the individual. In this 
way the gastric function will not be overtaxed and the stomach 
will be spared and enabled more readily to regain its normal tone 
than if it is continuously overloaded with food that it can only 
digest with difficultv or not at all. 



THE USE AND ABUSE OF HYDROCHLORIC ACID. 

The administration of hydrochloric acid as a routine measure Hydrochloric 
in gastric disorders is being abandoned since more careful chem- aci 
ical examinations of the stomach contents are being universally 
made and treatment is governed accordingly. It is self-evident 
that the administration of hydrochloric acid is, to say the least, 
superfluous, if not directly harmful in cases of dyspepsia in 
which the stomach contents or the vomit show a reaction for free Dangers of 
hydrochloric acid (congo paper or phloroglucin vanillin test). ™, tine use °* 
In cases in which free hydrochloric acid is absent and in which 



360 



CHRONIC GASTRITIS 



HC1 to replace 
the deficit of 
HC1 in the 
stomach 



Inadequacy of 
this treatment 



Disadvantages 
of giving much 
HC1 



Effect of HC1 
on flow of gas- 
tric HC1 



the total acidity of the stomach contents is greatly reduced, hy- 
drochloric acid may, to advantage, be given, first, as an aid to the 
digestion of albumens in the stomach, i. e., in order to render 
peptic digestion possible; second, as an antizymotic, i. e., in order 
to stop abnormal fermentation in the stomach ; third, as a stom- 
achic, i. e., to stimulate the outpouring of gastric juice. 

The administration .of hydrochloric acid for the purpose of 
replacing the deficit of hydrochloric acid in the stomach is a sub- 
stitution therapy. The effect of this treatment is greatly over- 
estimated. The small doses of five or eight drops that are com- 
monly given after eating are practically useless and hydrochloric 
acid, in order to be effective at all, must be given in very much 
larger doses. It has been shown by direct experimentation that 
one cannot give enough hydrochloric acid with an albuminous 
diet to cause the appearance of free hydrochloric acid in the 
stomach contents, unless such enormous doses are given that the 
patient would be poisoned. One part of hydrochloric acid sat- 
urates eighteen parts of albumen, and as a hundred drops of 
dilute hydrochloric acid contain only 0.8 gm. of HC1, this amount 
would only be sufficient to neutralize fifteen grammes of albumen. 

In order to aid the peptic digestion of albumens, fifteen to 
twenty drops of dilute hydrochloric acid in about 100 cc. 
of water should be given immediately after eating, and the same 
dose repeated every hour thereafter for three or four doses; or 
the same dose may be given immediately after eating and every 
fifteen minutes thereafter for three or four doses. The introduc- 
tion of such large quantities of water is, however, not without 
detriment. Some patients react to the administration of so much 
hydrochloric acid by gastric distress and pain, and unless the 
remedy is taken through a glass tube the teeth may be injured; 
all these disadvantages render the administration of hydrochloric 
acid as a substitute for the gastric hydrochloric acid a rather 
hazardous and by no means always an effective procedure. 

Whereas, therefore, the administration of hydrochloric acid 
as a direct substitute for the deficient hydrochloric acid in the 
gastric contents is a procedure of doubtful efficacy, regarded 
from the purely chemical standpoint, we know, clinically, that 
the exhibition of much smaller doses than those required accord- 
ing to the above reasoning are occasionally useful in relieving 
dyspeptic symptoms. This may be due to the fact that hydro- 
chloric acid stimulates the flow of gastric juice. This point, how- 
ever, is still uncertain, for the cases in which an increased flow 
of gastric juice seemed to follow the administration of free 
hydrochloric acid are not without ambiguity. It is not impossi- 



CHRONIC GASTRITIS 361 

ble that the administration of some hydrochloric acid after eating 
acts as a rest cure, so to say, to the hydrochloric acid glands of 
the stomach by relieving them of some of the labor necessary to ^^testinal 
manufacture hydrochloric acid, and hence enables them to more digestion 
readily regain their normal tone. Hydrochloric acid is also known 
to stimulate the pancreatic secretion and therefore it may aid 
intestinal digestion and, provided the motor power of the stom- 
ach is good, promote the vicarious disassimilation of the albumens 
in the bowel. 

If it is desired to utilize the stimulating effect of hydrochloric HC1 before 
acid upon the flow of gastric juice and upon the pancreatic secre- 
tion, the remedy should be given in doses of ten to twenty drops 
-diluted with about 100 cc. of water, a quarter to half an 
hour before eating. Administered in this way its full stomachic 
effect becomes promptly manifest. The administration of hydro- 
chloric acid in this manner is by far more rational and generally 
much more effective than the administration of larger doses dur- 
ing the meal or immediately afterwards. Hydrochloric acid 
administered in this way also stimulates the appetite. 

In some cases it appears moreover to increase peristalsis HC1 as an in- 
and to act, in a sense, as an intestinal antiseptic; so that it is septic antl " 
particularly useful in the treatment of the diarrhea and fermen- 
tative intestinal dyspepsia that so often complicates chronic 
gastritis. 

Aside from its action as a digestant and as a stomachic, H C1 as an an- 
hydrochloric acid is also administered for the purpose lzymo 1C 
of holding the pullulation of saccharophytes in the stom- 
ach in check. Fermentation due to various moulds, fungi 
and bacteria is particularly active in the stomach in cases 
in which the hydrochloric acid secretion is reduced and in 
which stagnation of stomach contents occurs. It is very 
•questionable whether the administration even of large doses 
of hydrochloric acid can stop fully developed fermentation 
in the stomach; as a prophylactic, however, given before meals, 
the administration of hydrochloric acid is exceedingly useful; 
for by this practice we are imitating Nature 's mode of preventing 
overgrowth of fermentative micro-organisms in the stomach. 
Here, too, then the administration of small doses of hydrochloric 
acid on an empty stomach is effective, whereas the administra- 
tion of large doses during or after meals is of very little value. 

DRUGS IN CHRONIC GASTRITIS. 

Alkalies are frequently administered in cases of hypochlor- Alkalies 
Tiydria or gastric anacidity on the supposition that they act as 
stimulants to the flow of hydrochloric acid, especially if given 



362 



CHRONIC GASTRITIS 



Alkalies be- 
fore and after 
meals 



Stomachics 
Bitters 



before meals. It has been claimed that a reactive outpouring of 
hydrochloric acid occurs upon their administration which is in- 
tended to neutralize the alkali placed into the stomach. Experi- 
mental and clinical evidence, however, demonstrates this suppo- 
sition to be wrong. It is true that in healthy subjects certain of 
the alkalies given on an empty stomach can cause some increased 
outpouring of gastric juice, but they share this property with 
any other drug that might be poured into an empty stomach and 
that irritates the gastric mucosa ; but they do not fulfill this pur- 
pose so well as the bitters or stomachics to be presently discussed. 

The administration of alkalies before meals is, of course, an 
exceedingly useful procedure in gastric hypersecretion and 
hyperchlorhydria on account of the antacid action they exercise 
(see page 397), and the same antacid properties render them 
useful when administered after meals, not only in the hyper- 
acidity that is due to an excessive outpouring of hydrochloric 
acid, but also in gastric acidity due to the formation of abnormal 
organic acids by fermentative micro-organisms. In the symptom- 
atic treatment of chronic gastric catarrh they have a place, there- 
fore, as neutralizers of organic acid and also of excessive hydro- 
chloric acid in those rare cases of chronic gastric catarrh that 
are accompanied by hyperchlorhydria. Furthermore, alkalies 
are useful in dissolving the mucus in chronic gastric catarrh. 
Much better, however, than the administration of alkalies by 
swallowing either for the purpose of neutralizing organic acids 
or dissolving mucus is their introduction into the stomach by 
means of the stomach tube when lavage is performed (see above). 
As the formation of organic acids and stagnation of stomach 
contents does not occur, however, in gastric catarrh if proper 
lavage is instituted, and as the administration of alkalies after 
meals would neutralize small amounts of hydrochloric acid that 
are usually formed in chronic gastric catarrh, their utility as a 
medicine in this disease is very limited. Their employment in 
hypersecretion and hyperchlorhydria complicating gastric 
catarrh will be discussed in the section on these disorders. 

Medicines belonging to the group of stomachics and simple 
bitters are very useful in chronic gastric catarrh. In most cases 
they increase the appetite, stimulate the flow of gastric juice and 
increase the motor power of the stomach. They are especially 
useful in cases of chronic gastritis accompanied by a reduction 
of hydrochloric acid, but they are distinctly contra-indicated in 
hyperchlorhydria of any kind. Whereas, from a pharmaco- 
logic standpoint two groups of remedies, viz. : stomachics and 
bitters, may, somewhat artificially, be distinguished, from a prac- 
tical, i. e., clinical standpoint, this differentiation is altogether 



CHRONIC GASTRITIS 363 

superfluous. As a matter of fact, we know very little of the Mode of action 
exact mode of action of the stomachics and bitters, and the litera- 
ture is full of contradictory statements in regard to their 
efficacy. Some of the remedies of this group produce hyperemia 
of the gastric mucosa, others possibly exercise a directly stimu- 
lating effect upon the gastric glands. Inasmuch as all these 
remedies have a different composition and origin and are in no 
way related to one another chemically, but as they all have in 
common both their effect upon the appetite and digestion and 
their bitter taste, it seems reasonable to attribute their chief in- 
fluence to the latter property. It is quite probable, especially 
in the light of Pawlow's recent researches, that they act on the 
gastric digestion and upon the appetite through nervous reflexes 
emanating from the mouth, i. e., by their taste, producing, like 
many other substances with pungent odors or strong tastes, a 

reflex secretion of gastric juice. Besides, a certain psychic effect 
resulting from the popular prejudice in favor of bitter remedies 
as efficient stomachics cannot be excluded. 

The number of stomachics and bitters is very great, and it Gentian 
is a difficult matter to select from them. The most popular are Quassia 
the following: Gentian, given as the fluid extract in ten to Conduran p 

thirty minims (0.7 to 2 cc.) or as the compound tincture of gen- cinchona 
tian in the dose of one-half to four drachms (2 to 16 cc); 
quassia, as the tincture, fifteen to sixty minims (1 to 4 cc.) or 

the fluid extract, five to thirty minims (0.3 to 2 cc.) ; condurango, 
as the fluid extract, fifteen to twenty minims (1 to 1.3 cc.) or 
the wine of condurango, two to four drachms (8 to 16 cc). In 
place of these simple bitters preparations of mix vomica, one to 

five minims (0.06 to 0.3 cc.) of the tincture; cinchona, as the 

tincture, one to four drachms (4 to 15 cc.) or the fluid extract of 

cinchona in one drachm (4 cc) doses. 

Many drugs of the volatile oil series containing, in addition Cardamoms 

to the aromatic oils some bitter principle, are also used; for in- Cinnamon 

stance, the tinctures of cardamoms, cinnamon, anis, nutmeg", cara- , T ms 

Nutm.es? 

way, bitter almonds and many others in the form of spirits, caraway 
waters, tinctures, fluid extracts or infusions, and, besides, certain Bitter Almonds 
of the peppers and mustard. Peppers 

A very useful synthetic remedy that, in some instances, exer- Mustard 
cises a remarkably stimulating effect upon the appetite, is 
orexine. Orexine itself, if given in large doses, may cause a burn- Orexine 
ing sensation along the esophagus and in the stomach, and, in 
susceptible subjects, nausea and vomiting. Basic orexine is the 
best preparation, as it is only slightly irritating to the stomach Basic orexine 
and, in nearly all cases, produces an increased flow of gastric 



364 



CHRONIC GASTRITIS 



Digestive fer- 
ments 



Pepsin 



juice, aids digestion and stimulates the appetite. Basic orexine 
should be given in capsule containing five grains (0.3 gm.) in 
the middle of the afternoon with a full glass of water or milk ; 
or one can begin with a smaller dose of two grains (0.1 gm.) on 
the first day and increase it by a grain or two a day until a dose 
of five or six grains is reached. In either case the remedy should 
be taken only for four or five days; within this period good re- 
sults are usually obtained. After the fourth or fifth day the fur- 
ther administration of the remedy is generally superfluous, espe- 
cially as its effect wears off. It is often good practice to stop 
the administration of orexine for a week and then to resume the 
use of the medicine for four or five days again. 

THE USE OF DIGESTIVE FERMENTS. 

The administration of digestive ferments, pepsin, pancreatin, 
ptyalin, as well as of certain vegetable ferments with proteolytic 
or diastatic properties, is very popular. The utility of these 
products in dyspeptic disorders, is, however, highly problematic. 

Pepsin is indicated on theoretical grounds where the secre- 
tion of pepsin by the gastric glands is deficient. This is a very 
rare event ; for it will be found that even in those cases in which 
the hydrochloric acid secretion is very low, pepsin, or at least 
pepsinogen, is excreted and that the albumen digesting power 
of the gastric juice is small, not on account of the pepsin deficit, 
but for lack of hydrochloric acid. In an overwhelming ma- 
jority of these cases the addition of hydrochloric acid to the 
gastric juice will promptly restore its proteolytic power, so that 
stimulation of the flow of hydrochloric acid or the administration 
of large quantities (see above) of hydrochloric acid is all that is 
required. The administration of pepsin, itself, is indicated, 
therefore, only in those cases in which the gastric contents, ren- 
dered acid with hydrochloric acid, fails to digest proteids. To 
administer pepsin when free hydrochloric acid is present in the 
stomach contents is altogether futile, for it has been shown that, 
when free hydrochloric acid is present, pepsin is always secreted 
in abundant quantities. In rare cases of achylia gastrica, in 
nervous anacidity and apepsia, in atrophy of the gastric glands 
and occasionally in gastric carcinoma pepsin may be of some 
value. In certain advanced cases of chronic gastric catarrh, in 
which the pepsin secretion is reduced on account of functional 
weakness of the peptic glands, the administration of pepsin in 
combination with hydrochloric acid may also aid to some extent 
both by actually furnishing pepsin and by relieving the peptic 
glands of the labor of secreting pepsin, hence sparing them and 
enabling them better to regain their normal function. 



CHRONIC GASTRITIS 365 

The popular wines and essences of pepsin are always weak Preparations 
and frequently possess no proteolytic power whatsoever ; in fact, p 
the alcohol they contain somewhat impairs the action of the pep- 
sin. These remedies, besides, if given in large quantities, may 
injure the stomach. The official pepsin of the U. S. P., made 
from the glandular layer of pig's stomach, should be capable of 
digesting not less than three thousand times its weight of coagu- 
lated egg albumen. It is dispensed in powder form or as fine 
scales, either in capsules containing five to ten grains (0.3 to 0.6 
gm.), or in a 0.2 per cent, hydrochloric acid solution, immediately 
after or during meals. 

Papain (papayotin or papoid), a product made from carica Papain 
papaya, and bromelin made from pineapple and cradin from Broinelin 
ficus carica, all possess considerable proteolytic powers. 

The best of this group is papain, which does not digest pro- 
teids as energetically nor as rapidly as pepsin, but possesses this 
advantage over pepsin, that it digests albumen not only in an 
acid but also in a neutral or alkaline medium, so that it continues 
its effect after it has left the stomach. 

Pancreatin, a mixture of the enzymes of the pancreas, is ad- Pancreatin 
ministered in powder or capsule in the dose of two to five grains 
(0.1 to 0.3 gm.) only if the secretion of hydrochloric acid is 
reduced, or if hydrochloric acid is altogether absent from the 
stomach; for it does not act in an acid medium and is rapidly 
destroyed by the action of hydrochloric acid in the stomach. If 
some hydrochloric acid is present in the gastric juice, then this 
must be neutralized by administering sufficient soda with pan- 
creatin. In this way pancreatic digestion is, so to say, trans- 
ferred to the stomach. Inasmuch as the pancreatic secretion is 
rarely impaired in gastric disorders, it is much more rational to 
promote rapid propulsion of the stomach contents into the bowel, 
for there the food is at once exposed to the action of the normal 
pancreatic ferments. In cases of insufficiency of the pancreatic 
secretion in the bowel (a condition that it is almost impossible to 
diagnose), pancreatin might be given in gelatin capsules that 
withstand the hydrochloric acid of the stomach; or pancreon, a Pancreon 
tannic acid precipitate of pancreas, may be administered, for this 
remedy resists the action of the gastric juice for four or five 
hours. It may be given in doses of five grains (0.3 gm.) in 
watery solution, during meals, if hydrochloric acid is absent, 
half an hour before meals if hydrochloric acid is present in the 
stomach. It will be seen, therefore, that in chronic gastric 
catarrh the use of pancreas preparations is very limited. Pan- 
creas preparations as well as amylolytic, i. e., starch digesting fer- 



366 



GASTRIC ULCER 



Amylolytic 

ferments 

Ptyalin 

Diastase 

Taka-diastase 

Treatment of 
special symp- 
toms 



Nausea 

Vomiting 

Pain 

Belching 

Meteorism 

Constipation 

Diarrhea 



ments as, for instance, ptyalin made from salivary glands, malt 
diastase (malt extract, maltzyme, maltine, etc.) takadiastase 
(from aspergillus oryza) are indicated only in gastric hyper- 
acidity in combination with alkalies; hence they are practically 
never used in chronic gastric catarrh. 

With the introduction of systematic lavage, the judicious use 
of hydrochloric acid and stomachics, and the proper administra- 
tion of a carefully selected diet to fit the state of the gastric 
function as determined by analysis of the stomach contents, the 
use of medicines for the treatment of special symptoms like nau- 
sea, vomiting, gastric pain, belching, meteorism, diarrhea and 
constipation has become practically needless. If the decompos- 
ing and fermenting contents and the offending mucus are re- 
moved at frequent intervals by lavage with alkaline waters, the 
formation of gases and of irritating acids in the stomach and 
their propulsion into the bowel is to a large extent prevented. 
Hydrochloric acid, judiciously administered, also in a measure 
impedes the formation of toxic bodies and aids in the proper dis- 
assimilation of the food, hence increases the appetite and the gen- 
eral nutrition. No occasion, therefore, under this treatment is 
given for the development of nausea, vomiting, belching, meteor- 
ism or diarrhea. The constipation, if persistent, should be com- 
bated chiefly by the ingestion of abundant fresh fruits and vege- 
tables, by laxative mineral waters, occasionally by a little rhu- 
barb and by enemata, but not by strong vegetable or mineral 
purgatives, as the latter may seriously injure the irritated and 
inflamed gastric mucosa and hence impede the healing process. 
Severe and persistent gastric pain can, as a rule, be effectually 
stopped by the application of Priessnitz compresses or of hot 
water bags to the epigastrium, so that the use of narcotics will 
rarely become necessary. Hyperchlorhydria complicating chronic 
gastritis and producing pain (a rare event) should be combated 
according to the principles discussed in full in another section. 



General indi- 
cations 



GASTRIC ULCER. 
The healing of an ulcer of the stomach is, self evidently, accel- 
erated if the stomach walls are kept in a quiet, contracted condi- 
tion and if the surface of the ulcer is protected, so far as that is 
possible, from, mechanical, thermic and chemical iritation. An 
ulcer of the stomach differs in this respect in no way from an 
ulcer located in any other part of the body; for anywhere healing 
is promoted by quiet of the adjacent parts, the avoidance of 
stretching and the protection of the surfaces of the ulcer from 
extraneous irritants. 



GASTRIC ULCER 367 

In gastric ulcer certain difficulties inherent in the character 
of the ulcer, the peculiar anatomy of the stomach and the nature 
of its functions, are encountered that render the carrying out 
of this plan very difficult. Complete rest of the stomach wall 
and avoidance of distention, as well as protection of the ulcer 
surfaces, can only be procured by withholding all food for a time, 
and later by carefully administering liquid, soft, bland foods of 
moderate temperature ; at the same time, the acidity of the stom- 
ach contents, which is usually increased in ulcer, must be re- 
duced by appropriate feeding and medication; and the healing 
of the ulcer, so far as that is possible, stimulated by direct 
medication. Above all things, during this time every effort must 
be advanced to maintain the patient 's general nutrition, as other- 
wise the organism becomes unfit to put forward its best efforts 
towards promoting regeneration and healing in the affected area. 

Inasmuch as ulcer of the stomach is presumably always pro- 
duced by some mechanical agency, trauma, thrombosis, etc., af- prophylactic 
fecting either a healthy subject or an individual suffering from treatment 
anemia, chlorosis or circulatory disorders in the stomach wall, 
causal treatment is manifestly impossible. This is due to the 
fact that the injury that directly produces the ulcer cannot be 
anticipated nor forestalled, so that prophylaxis in the broader 
sense is out of the question. 

We know, however, that the failure of gastric ulcer to heal 
as promptly as ulcers in other parts of the body, and its ten- impede healing 
dency to extend, must, in large part, be attributed to the hyper- and favor ex- 
chlorhydria that usually accompanies gastric ulcer; we know 
further that anemia and chlorosis not only predispose to gastric 
ulcer, but impede its healing ; hence in the presence of the gastric 
ulcer treatment should always be directed towards correcting 
gastric hyperacidity and any anemia or chlorosis that may exist, 
according to methods that are described in full in appropriate 
sections. 

Complete abstinence from food foi.' a period of time, fluctuat- Complete absti- 
ing from a few days to several weeks according to the peculiar nence from 
exigencies of the case, is always good practice. In most cases it 
is safe to resume the administration of some fo^d after the fifth 
day, for equally good results are generally obtained from this 
course, provided the feeding is carefulry instituced according to 
the principles to be presently discussed, as from total abstinence 
from food for a period of several weeks. The latter plan of treat- Feeding after 
ment, which is now very popular, is, therefore, as a rule, unneces- fifth day 
sarily severe, moreover very difficult to carry out on account of 
the unwillingness on the part of the patient to undergo such a 



368 



GASTRIC ULCER 



Disadvantages 
of rectal feed- 
ing 



Indications for 
rectal feeding 



Rest in bed 



Heat and cold 
to epigastrium 



Exercise during 
convalescence 



Thirst 



Rectal irriga- 
tion 



Rectal feeding 



trying ordeal ; above all, there is much difficulty in most cases to 
maintain adequate nutrition by rectal feeding (see below) alone. 
When one considers, furthermore, that rectal feeding undoubted- 
ly stimulates gastric secretion to some extent (one of the factors 
one is precisely trying to avoid by withholding food by mouth), 
this plan of treatment seems particularly useless in most cases. 

In patients suffering from severe gastric pain and vomiting, 
and notably from repeated hemorrhage from th* stomach, when- 
ever food is administered, the total abstinence plan with rectal 
feeding may, however, have to be reluctantly instituted for long 
periods of time, i. e., until all these symptoms disappear, or until, 
especially in cases of persistent hemorrhage, the proper time- 
arrives for surgical intervention (see below). 

A patient with gastric ulcer should always be kept in bed 
for a period of at least two weeks, or preferably longer, particu- 
larly if there is a tendency to hemorrhage or if symptoms of peri- 
toneal irritation or inflammation are present. In the latter event 
the application of an ice bag or of a Leiter coil to the epigastric 
region is a useful measure, otherwise Priessnitz compresses or 
hot poultices, or a hot water bag for several hours each day, are 
more grateful to the patient. While in bed all violent movements 
should be carefully avoided and the patient should not be al- 
lowed to get out of bed even for the purpose of emptying the 
bladder or rectum. During the third and fourtn weeks of treat- 
ment the patient may be permitted to sit up for a little while 
each day, and later take short walks about the room, and still 
later out-of-doors. For several weeks after the ulcer symptoms 
have disappeared, it is always a good plan to instruct the patient 
to lie down for an hour after each meal. 

During the period of total abstinence from food, the distress- 
ing sensation of thirst that so many complain of should be coun- 
teracted by frequently washing the mouth with cold water and 
allowing the patient to suck ice pills without swallowing the 
water. The demands of the organism for water should be ful- 
filled by rectal irrigation; i. e., from 250 to 500 cc. of normal salt 
solution containing eight to ten grammes of sodium chloride to 
the litre of water should be injected, lukewarm, into the rectum, 
several times a day. If it is desired to slightly stimulate the pa- 
tient, a little brandy or white wine may be added to this water 
enema, or a little bouillon may be used on account of its stimu- 
lating effect. 

In feeding a patient by the rectal route one should proceed 
as follows: Prior to the injection of the nutritive enema, the 
lower bowel should be carefully washed out with warm, soapy 
water. An hour later, or sooner if all the wash water has been 



GASTRIC ULCER 369 

expelled, the nutritive clysma should be injected by means of 
a soft rubber catheter and an irrigating bag elevated about three 
feet above the patient. The tube should be introduced as far as 
possible into the colon. The patient should lie on the left side 
with the right leg drawn up and the hips elevated by a pillow or 
two. After the clysma has been injected the patient should re- 
main perfectly quiet, preferably in the same position, for about 
an hour. The temperature of the enema should approximate 
that of the body. If the patient is unable to hold the enema, 
or if the clysma produces too much irritation, an event that is 
especially apt to occur if peptones or albumoses are used, then 
ten to twenty drops of the tincture of opium may be added to 
the enema. The total amount of the clysma should not exceed 
250 cc. Rectal feeding may. be instituted in this way two or 
three times a day. 

Many nutritive enemata of different composition have been Nutritive ene- 
described, for nearly every author who has written on this sub- mata 
ject has devised some new mixture. One of the best and simplest 
forms of nutritive enemata that answers all purposes if rectal 
feeding is to be instituted for a short time only, and this is 
usually the case, is the following : 



250 cc. milk. 

2 yolks of egg. 

2 tablespoonfuls of claret. 

A pinch of salt. 

The addition of salt to nutritive enemata is very important, Addition of 
for it has been shown conclusively that the addition of sodium salt 
chloride greatly aids in the absorption of the nutrient bodies con- 
tained in the enema. The action of the salt is probably attribu- 
table to its power to stimulate antiperistalsis and hence to cause 
food injected into the rectum or colon to be carried into the small 
intestine, where absorption is much more active than in the lower 
bowel. 

Peptones and albumoses, i. e., predigested albumens, aside Peptones and 
from irritating the bowel in many cases are not absorbed more alb umoses 
rapidly than native albumen itself, hence theii addition to nu- 
tritive enemata, which is commonly recommerded, is usually 
superfluous. Nevertheless, the following clysma, recommended 
by Singer, is very popular and occasionally serves a useful pur- 
pose : 



370 



GASTRIC ULCER 



Ewald's nutri- 
tive enema 



"Egg enema 



Feeding after 
abstinence 



Milk 



Exclusive milk 
feeding 1 not 
practical 



Milk powder 

Condensed 

milk 



Buttermilk, 

kephyr, 

kumyss 



125 ec. of milk. 

125 cc. of claret. 

2 yolks of eggs. 

A little salt. 

A dessertspoonful of Witte 's peptone. 

The different sugars are rapidly absorbed from the intestine, 
but, as they easily undergo decomposition and kad to fermenta- 
tive gas formation and distention of the bowel, their use cannot 
be particularly recommended. Of the various sugars that can be 
used dextrose is the most valuable, but its extensive employment 
is rendered impracticable by its cost. A simple nutritive enema 
recommended by Ewald and containing dextrose is made as fol- 
lows: 

Two or three eggs are mixed with a tablespoonful of cold 
water. A little flour is boiled in half a cup of a twenty per cent, 
dextrose solution and allowed to cool. To this solution a wine 
glass full of claret is added, the egg solution stirred in and the 
mixture filled up with water to 250 cc. 

When using eggs for a nutrient enema the bowels should be 
thoroughly cleansed about an hour or two later, as otherwise 
decomposition of the egg albumen in the rectum may occur and 
toxic putrefactive bodies that are highly irritating be formed. 

After four or five days of total abstinence from food with 
rectal feeding, milk should be carefully administered by mouth, 
at first in small doses of two or three tablespoonfuls, boiled and 
cold. After a hemorrhage it is best to give still smaller quantities 
of iced milk every two or three hours, or every hour. If the 
milk causes vomiting, and especially if large curds form, an 
event that is not uncommon if raw milk is administered but 
is not so apt to happen if the milk is boiled, the addition of a 
little lime water or of soda, or the administration of tablespoon- 
ful doses of ice cold milk at frequent intervals may stop these 
symptoms and enable the patient to take the milk by mouth. 
The latter mode of administration is also efficacious in subjects 
who manifest a severe dislike to milk. 

Exclusive milk feeding is never a feasible plan, for, in order 
to adequately nourish the patient with milk alone far too much 
liquid must be introduced, and if the patient is to be fed with 
small quantities of milk at a time the administration of milk 
would have to be practically continuous throughout the day; 
for this reason the addition of milk powder, 100 grammes to the 
litre of milk, or of one to two teaspoonfuls of condensed milk to 
the litre of milk, may be practised in order to increase the nutri- 
tive value of the milk. In order to afford variety, buttermilk, 
keph3 T r or kumyss may be tried, but it must be remembered that 



GASTRIC ULCER 371 

all these milk products contain less fat and sugar than milk, and 

Gruels 

are hence less nourishing. Within the first ten days after total 
abstinence from food a little tapioca, rice, wheat, barley or oat- 
meal flour may be boiled in milk and these gruels given in place 
of milk alone. 

A very useful, nutritious and non-irritating addition to the 
bill of fare during this period is meat jelly prepared, according to 
Fleiner, by boiling chicken or beef with a calf's foot for several 
hours with the addition of a little salt. The soup, cooked in this 
way, is cleared by stirring in an egg and heating to a boil, the 
fluid is strained off and on cooling coagulates to a jelly. Of this 
meat jelly a dessertspoonful may be given every few hours. 
During this period, too, albumen water, made by dissolving white Albumen 
of egg in salt water, or an egg stirred up in a little bouillon, may water 
also be allowed. Twenty per cent, solutions of dextrose in milk Dextrose so- 
or water are also permissible. Such a sugar solution is quite lution 
nutritious and also possesses some antacid properties that are 
beneficial. 

On this simple diet, usually reinforced by one or two recta] Diet during 
feedings a day, the patient remains for the first ten days. Dur- second ten days 
ing the second ten days of the ulcer cure the amount of the gruels 
is gradually increased and some of the soft and digestible meats, 
like squab, chicken, calves' brains, scraped raw meat, also a little 
mashed potato, boiled rice, noodles or macaroni, tapioca, sago, a 
little boiled cauliflower or zwieback soaked in milk may be al- 
lowed. 

Later still, i. e., during the third and fourth week, a little Diet during 
roast beef, beef steak, poultry, some boiled fish, vegetable purees * hird . , and , 
made of green peas, beans, carrots, a little chopped spinach, as- 
paragus tips, some scrambled eggs or an omelet, may be per- 
mitted. 

As a more liberal diet is resumed, particular care should be Diet during 
exercised to exclude all mechanically irritating foods, as certain convalescence 
cereals and vegetables containing husks, stems, pips, skins or 
stalks, as well as berries, on account of their seeds, hard bread 
crusts, etc. Very hot or very cold foods and drinks, spices, con- 
diments, strong alcoholic beverages and coffee are best avoided. 
It is always safer to administer small meals at frequent intervals 
than two or three large meals a day, even for weeks after the 
ulcer has healed. 

A very useful measure, adopted almost as a routine in Euro- Carlsbad 
pean clinics, is the administration of one or two teaspoonfuls of salts 
Carlsbad salts dissolved in 250 cc. of water every morning on an 
empty stomach. The chief ingredients of Carlsbad salts are 
sodium chloride, sodium carbonate and sodium sulphate, and it 



372 



GASTRIC ULCER 



Reduction of 
hyperacidity 



Antacids 



is difficult to explain the beneficial action derived from the use 
of this mixture. It is probable that it acts in several ways, by 
dissolving the mucus, by neutralizing the excessive acidity and 
as a laxative. 

The reduction of hyperacidity, which is a very important 
element in the treatment of gastric ulcer, will be discussed in full 
in a separate section (page 393f ). In ulcer cases living on a diet 
consisting largely of milk and eggs, the hydrochloric acid of the 
gastric juice is partially neutralized by the latter, for the albu- 
men they contain possesses slight antacid properties. The addi- 
tion of an alkali, either a tablespoonful of lime water to each 
glass of milk, or soda or magnesia, enforces this effect. 

A very popular method of treating hyperacidity in gastric 
ulcer is by means of the following mixture : 



3 



Sodium carbonate, 

Burnt magnesia, of each, 100 parts 

Sugar of milk, 150 parts 



Carlsbad 
Salts 



Atropine 
Belladonna 



Silver nitrate 



This mixture is procured in bulk and the patient adds half 
a teaspoonful to each glass of milk. Carlsbad water or Carlsbad 
salts may also be used as an antacid addition to the milk, or 
Carlsbad salts may be taken immediately after each meal. If 
there is hyperacidity occurring not only after eating, but also 
hyper-secretion, so that acid gastric juice is present when the 
stomach is empty, then it may become necessary to administer 
alkalies between meals. In very excessive degrees of hyper- 
acidity that cannot be readily controlled by the administration 
of alkalies, the use of atropine or belladonna may be required. 
The former should be given hypodermically in the dose of one 
hundredth of a grain (0.6 mg.) once or twice a day, the latter as 
the extract of belladonna by mouth in capsule with an alkaline 
water in the dose of a quarter grain (0.01 gm.) three times a day. 

Another remedy used as an antacid and credited, moreover, 
with healing properties in gastric ulcer, is silver nitrate. This 
drug seems to be of particular value if much pain is complained 
of when the stomach is empty and also in gastric hyperesthesia 
with abnormal sensitiveness to the introduction of food. As silver 
nitrate neutralizes hydrochloric acid by precipitating the latter 
in the form of silver chloride, it is said to possess some antacid 
power, but, considering the small amounts of the drug that can 
be introduced, this effect is insignificant and the good sympto- 



GASTRIC ULCER 373 

matic results obtained from the use of silver nitrate in gastric 
ulcer must be attributed in large part to some influence exercised 
by the drug upon the sensory apparatus of the stomach that is 
not altogether understood. 

Silver nitrate is best given in a solution of the strength of Dose and ad- 
one to one thousand in tablespoonful doses, three or four times a 
day on an empty stomach. If this concentration is well borne 
the strength of the solution may be gradually increased to one 
and one-half to one thousand, then to two to one thousand, and 
the patient kept on tablespoonful doses of the stronger solutions 
three times a day throughout the course of the disease, i. e., for 
a period of from four to six weeks. Slight nausea and diarrhea 
that occasionally make their appearance in the beginning of this 
treatment are generally negligible, as these symptoms usually 
disappear spontaneously within a few days, and without special 
interference. The bad taste that patients taking silver nitrate 
solutions sometimes complain of can best be counteracted by pep- 
permint or eucalyptus lozenges. 

As an anesthetic chloroform water can also be used in gas- Chloroform 
trie ulcer, either alone, in the dose of a tablespoonful every two water 
or three hours, or in combination with bismuth in the following 
formula : 

i* 

Chloroform 1 gm. 

Distilled water 150 gm. 

Bismuth subnitrate 3 gm. 

One to two teaspoonfuls every hour (Stepp). 

A number of indifferent powders like bismuth subnitrate or Indifferent 
carbonate, orthoform, talcum, chalk, etc., may be used to advan- P owders 
tage in gastric ulcer, more on account of their mechanical effect 
than because of any medicinal properties they possess. These sub- 
stances form a thin coating over the ulcer surface, thus protect- 
ing it from the irritating action of the food and the gastric juice ; 
at the same time they act as hemostatics by forming a powder 
cake over the bleeding area ; they also generally relieve the pain. 

Bismuth subnitrate should be given in large doses of two or Bismuth sub- 
three drachms (8 to 12 gm.) suspended in about 100 cc. cartonatT* 
of water, on an empty stomach. If the ulcer can be localized, the 
patient, after swallowing this mixture, should occupy such a 
position that the ulcer is in the most dependent part of the stom- 
ach; i. e., if the ulcer is situated at the lesser curvature or on the 
posterior wall of the stomach, the patient should occupy the dor- 



374 



GASTRIC ULCER 



Introduction of 
bismuth by 
tube 



Orthoform 



Talcum-Chalk 
Magnesia mix- 
ture 



sal position with his hips elevated; if at the pyloric part, he 
should lie on the right side ; if on the anterior wall, he should lie 
on his face or occupy the knee-chest position. The appropriate 
posture should be maintained for about fifteen minutes to one 
hour. If the exact localization of the ulcer is impossible, and 
this will be the rule, the patient should lie for fifteen minutes 
successively on his back, his stomach, his left and his right side; 
in other words, he should perform complete rotation of the body 
within the space of an hour. 

It is rarely necessary to introduce the remedy through a stom- 
ach tube; this procedure, in fact, is never without danger, espe- 
cially in recent ulcer, in ulcer near the cardia or in ulcer with a 
tendency to hemorrhages. If it is decided, however, to give the 
bismuth by tube, the stomach should first be thoroughly washed 
out with slightly alkaline, lukewarm water and after the last 
of the wash water, which should be perfectly clear, has been 
pumped or siphoned out, two or three drachms (8 to 12 gm.) 
of bismuth subnitrate or carbonate, suspended in a 100 
cc. of lukewarm water should be poured into the fun- 
nel and washed down with a small quantity of water. The stom- 
ach tube should be left in place for five to ten minutes, in order 
to give the bismuth time to settle, then the water may be siphoned 
off and the tube withdrawn ; or the tube may be introduced a sec- 
ond time very carefully and the water drawn off in this way. 
The former procedure, however, is by far the more practical one 
of the two. Best of all and least disagreeable to the patient, is 
swallowing the bismuth mixture without the aid of the stomach 
tube. 

The bismuth treatment should be given from the beginning, 
at first every day, then every second day and later every third 
day. The effects from this therapy are generally very favorable 
and untoward symptoms on the part of the stomach, or poisoning 
from the absorption of bismuth (stomatitis, etc.), even when 
the drug is given in much larger doses than those indicated 
above, are never witnessed. 

Orthoform, as such, or in the form of its muriate, is as use- 
ful as bismuth subnitrate or carbonate; it should be given in 
doses of sixty to ninety grains (4 to 6 gm.) suspended in a 100 
cc. of water in the same way as bismuth. 

Bismuth salts and orthoform, especially if they are to be used 
in such large quantities, are quite expensive, and in private prac- 
tice the following mixture, recommended by Pariser, may be ad- 
vantageously used instead: 



GASTRIC ULCER 375 

Talcum 60 parts 

Chalk 60 parts 

Magnesia usta 15 parts 

Of this preparation five drachms are mixed with water and 
administered in the same way as bismuth. The slight antacid 
and laxative properties of the magnesia, and the fact that the 
ingredients of this mixture do not blacken the stools, and hence 
do not conceal small hemorrhages like bismuth, render this mode 
of treatment quite useful. 

Olive oil, too, may be used for its mechanical effect, especially Olive oil 
in cases of gastric ulcer with pyloric spasm due to intragastric 
irritation, with resulting dilatation of the stomach, stagnation of 
the stomach contents, and, consequently, irritation of the ulcer 
surface. Fifty cubic centimeters of olive oil may be introduced 
three times a day, or a hundred and fifty cubic centimeters taken 
on an empty stomach in the morning. The oil may either be swal- 
lowed or administered through the stomach tube. 

If the rest treatment, described above, the careful regulation 
of the diet after a period of total abstinence from food, antacid 
medication with alkalies or Carlsbad water and atropine, the 
silver nitrate, or the bismuth or orthoform treatment are insti- 
tuted, other measures intended to relieve special symptoms, nota- 
bly pain and vomiting, rarely become necessary. 

Narcotics should be used very sparingly and only in severe Narcotics 
cardialgia and gastric pain that does not yield to hot applica- 
tions to the epigastrium, antacid medication and the proper diet 
or total abstinence. The fact must never be forgotten that 
opium and morphine, aside from causing constipation, which is 
detrimental, increase gastric secretion, and hence favor precisely 
the outpouring of hydrochloric acid which is in most instances 
producing the pain in gastric ulcer. Narcotics, therefore, while 
they deaden the sensibility of the gastric nerves, favor the cause 
that irritates them. 

In most instances one must experiment with the use of hot or Hot and cold 
cold applications, some patients experiencing greater relief from 1 a 10ns 

the application of heat in the form of a hot water bag, poultices 
or the thermophore (see index), others being relieved by cold 
applied in the form of the ice bag, the Leiter coil or Priessnitz 
compresses. 

Hematemesis always calls for active treatment. Broadly Hematemesis 
speaking a recent hemorrhage or a tendency to recurrent hemor- 
rhages precludes the application of heat to the epigastrium; here 



376 



GASTRIC ULCER 



Hemostatic 
drugs 



Adrenalin 
chloride 



Opium 
Morphine 



cold applied to this region is always safer. Total abstinence 
from solid food should be insisted upon until all traces of blood, 
as determined by daily chemical tests, disappear from the stools. 
During this time the nutrition of the patient should be main- 
tained chiefly by rectal feeding. The patient should remain 
completely at rest in bed. Some patients do very well if they 
swallow teaspoonful doses of ice cold water at frequent intervals. 
If possible one should get along without the use of hemostatic 
remedies, and an opportunity for spontaneous cessation of the 
hemorrhage should be given; i. e., an expectant plan, as far as 
hemostatic drugs are concerned, should be followed for twenty- 
four hours, and the patient, during this time, treated by rest, 
cold applications and abstinence from food. If it becomes neces- 
sary to employ an hemostatic, the best remedy of all is probably 
adrenalin chloride, administered in the dose of ten to twenty 
drops of a one to one thousand solution, repeated at intervals 
of half an hour to an hour until the bleeding stops. At the same 
time excessive vomiting should be controlled by the use of opium 
or morphine given hypodermically or by suppository. Subcu- 
taneously, ergotine may be given in the following injection : 



Ergotine 



3 



Ergotine 
Glycerine 
Water 



2.5 gm. 

5.0 cc. 
5.0 cc 
(Eiegel) 



Hydrastis 



Lead acetate 

Bismuth 

Gelatin 



Other remedies that are occasionally useful are the fluid ex- 
tract of hydrastis, given in fifteen to sixty minim (1 to 4 cc.) 
doses, by mouth, or hydrastinine hydrochloride, in the dose of 
one-half to two grains (0.03 to 0.1 gm.) by mouth or hypodermi- 
cally. Lead acetate, in the dose of one grain (0.06 gm.) every 
two hours, or large doses of bismuth, may also prove useful. 

Gelatin sometimes stops hemorrhage; it is conveniently ad- 
ministered in the following combination: 



3 



Gelatin 


15.0 gm. 


Sodium chloride 


1.2 gm. 


Water 


200.00 cc. 



Of this mixture 100 cc. are to be given at once and 
the balance within two or three hours. The use of gelatin must 
be considered an extreme measure that will rarely have to be 



GASTRIC ULCER 377 

resorted to; in very profuse hemorrhages, however, it occasion- 
ally proves efficacious as an emergency measure. 

The after treatment of hemorrhage from gastric ulcer with Af ter treat- 

. merit 

loss of much blood is the same as that described at length in the 

sections on Hemoptysis and Secondary Anemia. During the 

hemorrhage and for some days afterwards, the bowels should 

be kept locked by the use of opium suppositories. After 

the bleeding has stopped, soft evacuations of the bowel contents 

should be promoted by the use of frequent enemata of soapsuds 

and water, glycerine, or oil, in order to avoid straining efforts 

at stool. 

Ulcers of the stomach that persist or show a tendency to re- indications for 
currence despite the adoption of all the measures outlined above, surgical treat- 
and in which there is much vomiting and pain, or occasionally a 
slight hemorrhage, with resulting mal-nutrition of the patient, 
may call for surgical intervention. Simple, uncomplicated ul- 
cers, however, rarely fail to yield to proper medical treatment 
carried out for a sufficiently long time, so that surgery has its 
chief field of usefulness in the treatment of the sequelae and 
complications of gastric ulcer rather than in the treatment of 
the ulcer itself. 

Repeated, severe hemorrhage may call for a laparotomy, liga- Repeated hem- 
tion of the bleeding arteries or excision of the ulcer area. A sin- orrhages 
gle severe hemorrhage rarely calls for surgical intervention, as 
statistics show that cases recover from such a hemorrhage with- 
out an operation as well as with an operation; in fact, the mor- 
tality is slightly higher if a laparotomy is performed in such 
cases than if it is not performed. 

Perforation of an ulcer with invasion of the peritoneum by s ure> i ca i treat- 
stomach contents; cicatricial contractures about the pylorus or ment of per- 
cardia causing stenosis; scar tissue forming in other regions of sion^and^ther 
the stomach, causing hour-glass contraction or diverticulum sequelae of 
formation ; perigastric adhesions producing dangerous traction or 
pressure symptoms on adjacent organs; perigastric abscess, are 
all sequelae and complications of gastric ulcer that, being mechan- 
ical in character, call for mechanical, i. e., surgical, relief. 

Whether the ulcer is to be excised (and it is well to remem- Excision of 
ber that recent ulcers are not always easy to find, and that ulcers ulcer or gastro- 
may be multiple and hence cannot all be excised) or whether a 
gastroenterostomy is to be performed must depend upon the pe- 
culiarities discovered when the abdomen is opened. It is, as a 
rule, impossible to predict before the laparotomy just what oper- 
ation shall be made. A discussion of the different operative pro- 
cedures that can be adopted lies without the frame of this book. 



378 



CARCINOMA OF THE STOMACH 



Surgery the 
only means of 
cure 



Resection of 
pylorus 



Gastroenter- 
ostomy 



CARCINOMA OF THE STOMACH. 

The main duty of the internist in the treatment of gastric 
carcinoma is to make the diagnosis as early as possible and then 
to order surgical intervention. In the case of this disease sur- 
gery is not a last resort, as in so many other disorders, to be 
tried only after the skill of the internist has been exhausted, but 
a first resort to be adopted as soon as the diagnosis is positively 
made, and the only resort that can bring about a cure of this 
affliction. It is by all means a safe and conservative plan, and 
one that would save many lives if adopted more frequently, to 
perform an exploratory laparotomy in every case of organic 
stenosis of the pylorus ; for no material harm is done in the hands 
of a skillful surgeon if the stricture after laparotomy should be 
found to be due to the presence of benign tissue; while if it 
should be found to be due to carcinomatous tissue, early resec- 
tion may be life-saving. It is unfortunale, however, that car- 
cinoma producing stenosis symptoms about I he pylorus is usually 
already far advanced. 

Resection of the cancer in most cases, therefore, is merely a 
palliative measure capable, often, of prolonging the patients'" 
existence, but rarely of curing them. At best even complete re- 
section of a gastric carcinoma leaves the patient with a stomach 
whose secretory and motor functions, owing to the atrophy of the 
gastric mucosa that almost invariably accompanies gastric car- 
cinoma, remain permanently impaired. 

Resection of the carcinoma is the operation of choice if the 
tumor is located in the pyloric region, if it is freely movable,, 
i. e., not adherent to adjacent parts, if no metastases are pres- 
ent and if the general condition of the patient is good. These 
indications, one must confess, are more or less theoretically con- 
structed, especially in regard to the absence of metastases, for 
it is self-evident that small metastatic growths in the liver or 
the mesentery may very well escape detection. 

If metastases are found, if the tumor is adherent or if it 
cannot be completely resected, if serious symptoms of stenosis 
about the pylorus with stagnation of gastric contents are pres- 
ent, then gastroenterostomy becomes a useful palliative opera- 
tion that often restores the patient to a condition of fair health 
and better nutrition for many months or even years, despite 
the presence of a carcinoma of the stomach. By producing an 
artificial passage from the stomach to the intestine, and thereby 
facilitating the passage of the food from the stomach into the 
bowel, stagnation of the gastric contents is prevented, digestion 



CARCINOMA OF THE STOMACH 379 

diverted altogether into the intestine and there vicariously car- 
ried on with more or less completeness, despite the atrophy of 
the gastric mucosa. At the same time the irritation of thp gas- 
tric carcinoma by food and by irritating decomposition products 
that arise from food stagnation is prevented and hence its 
growth retarded. 

In carcinoma involving the cardiac end of the stomach, pro- Gastrostomy 
vided dilatation of the cardia with bougies is not successful (and 
this measure only answers the purpose of keeping the cardia open 
temporarily) and in diffuse carcinomata of the stomach, the 
radical operation of gastrostomy must be thought of; for while 
the results of total extirpation of the stomach are not good and 
many early deaths have been reported from this operation, never- 
theless, this procedure may constitute a palliative measure in 
extreme cases that may enable the patient to live in comparative 
comfort for several months afterwards. 

If it has been determined that resection of the carcinoma is Conditions un- 
impossible; if the motor power of the stomach is so good that t( frnal treat^" 

gastroenterostomy appears a superfluous inroad ; if the case is ment is indi- 

n ...,-, cated 

seen too late xor a gastrostomy operation, m an advanced stage 

of cachexia or with metastases in various organs; if recurrences 
of gastric carcinoma appear after an operation and it does not seem 
feasible to operate a second time ; or, finally, if a patient afflicted 
with cancer of the stomach refuses an operation, then a num- 
ber of dietetic and medicinal means of treatment must be re- 
sorted to, all intended to maintain the general nutrition of the 
patient and to relieve a variety of distressing symptoms that 
may arise in the course of the disease. 

The regulation of the diet in gastric carcinoma is one of the Diet 
most important tasks of treatment. No set rules can be formu- 
lated as in the case of ulcer, and the selection of the diet must be 
governed chiefly by the state of the motor function and the pep- 
tic power of the stomach, as determined by frequent analyses of 
the stomach contents, as well as by the appetite, the particular 
likes and dislikes of the patient and his general state of nutri- 
tion. In most cases a fairly liberal diet is indicated. Every Liberal diet 
attempt should be made to allow the patient to enjoy his meals 
He should not, on the one hand, be forced to eat foods that he 
dislikes or that he knows do not agree with him even though such 
foods may be theoretically indicated, nor should he, on the other 
hand, be forbidden to eat articles that he craves and that he 
knows agree with him, unless they are absolutely harmful. 

To the latter class of foods belong all articles that undergo Harmful foods 
rapid fermentation; they are bad because in most cases of car- 



380 



CARCINOMA OF THE STOMACH 



No fermenting- 
foods 



No indigestible 
particles 

No large meals 



Aversion for 
meat 



Vegetable al- 
bumens 

Eggs 

Milk 



Gruels 
Bread 



Vegetables 

Fruits 

Tats 



Beverages 



Amount of 
liquid 



cinoma of the stomach there is, early in the disease, a deficiency 
or a lack of (anti- fermentative) hydrochloric acid and reduced 
motor power ; or if these conditions are not present in the begin- 
ning they are very apt to supervene sooner or later. In the 
second place, all articles of food that contain undigestible and 
mechanically irritating husks, stems, pips, seeds, tendons, car- 
tilage, skin and connective tissue must be considered detrimental 
to cases of carcinoma of the stomach. In the same sense large 
meals should always be forbidden, because they overtax the 
failing motor and peptic powers of the stomach; consequently 
small meals at frequent intervals should be advised. 

Most cases of carcinoma of the stomach instinctively have an 
aversion for meat; this is presumably a reflection in the appe- 
tite of the hydrochloric acid deficit. Meats should, therefore, be 
given sparingly and their administration never forced. Only soft 
and easily digestible varieties, like chicken, squab, calves' brains, 
sweet-breads, a little raw, scraped beef or rare steak or chop, 
fish, meat jelly should be given. 

If meat is altogether distasteful, or if it is not well borne, 
albumen must be supplied by milk and vegetable albumens 
(neutrose, tropon) and eggs, the latter soft boiled, scrambled, 
poached or as omelet, not hard boiled or fried. Milk may be 
served as described under Ulcer, or it may be rendered more 
nutritious by strengthening it with condensed milk or milk pow- 
der ; or it can be given in the form of gruels made of wheat, rice, 
oatmeal, barley, flour, or of arrow-root, sago, tapioca. Bread 
should be given in the form of old bread, toast, zwieback or 
crackers, never as hot bread. Of vegetables and fruits, cauli- 
flower, asparagus tips, fruit sauces, stewed fruits are permis- 
sible. Fats should be supplied not as animal fat but as vege- 
table or milk fat in the form of olive oil or mayonnaise on salad 
dressings, butter, cream or cocoa. There is a popular prejudice 
against the administration of fat in cases of carcinoma of the 
stomach, but it will usually be found that these patients can tol- 
erate considerable quantities of fat without digestive disturb- 
ances. 

The amount of liquid that should be introduced depends upon 
the motor power of the stomach. If there is much stenosis with 
gastric dilatation and stagnation of stomach contents, then the 
amount of liquids should be restricted and whatever beverages 
are administered should be given in small quantities. In extreme 
cases the ingestion of fluid by mouth should be restricted to the 
minimum compatible Avith comfort, and the water demands of 
the organism supplied by rectal irrigation as described elsewhere. 



CARCINOMA OF THE STOMACH 381 

In many cases dilute alcoholic liquors can du no harm. In Dilute alco- 
pronounced motor insufficiency, however, they are detrimental, hollc ll( l uors 
because the alcohol attracts water into the stomach. 

The administration of hydrochloric acid and digestive fer- Hydrochloric 
ments to replace e the deficient hydrochloric acid and pepsin in a ^ e ferments 5 " 
the stomach is of doubtful utility. As discussed in full in the 
Section on Gastritis, hydrochloric acid unless given in very large 
quantities does not aid materially in the digestion of albumen. 
If it is used at all, therefore, it should be given in ten to twenty 
drop doses in a 100 cc. of water, immediately after eating, 
and in the same dose three or four times afterwards at hour in- 
tervals. The advantages that might possibly accrue from the 
administration of the hydrochloric acid would, in cases of gas- 
tric carcinoma with motor insufficiency, be more than neutral- 
ized by the ingestion of abundant quantities of water that must 
be given with such large quantities of hydrochloric acid. Small 
quantities of hydrochloric acid are of very little value as a 
digestant unless we agree to attribute certain stomachic proper- 
ties to the remedy administered in this way. If given as a 
stomachic, the drug is more useful when administered on an 
empty stomach half an hour or an hour before eating. If the 
motor power of the stomach is good, the administration of hydro- 
chloric acid, and particularly of the ferments, is altogether super- 
fluous, as the digestion of the albumens can be fully carried 
out vicariously in the intestine. If on the other hand there is 
much stagnation of stomach contents on account of motor in- 
sufficiency, then the small quantities of pepsin or pancreatin or 
papaya preparation, that might be added to the fermenting gas- 
tric contents, will not be efficacious. 

If it is desired to administer a stomachic, any one of the rem- Stomachics 
edies discussed on page 362 may be given either alone or in com- 
bination with small doses of hydrochloric acid before each 
meal. The best stomachic of all, however, is removal of the 
stagnating stomach contents by lavage. The indication for lav- Lava §' e 
age is impaired motility of the stomach; so that in any case of 
carcinoma of the stomach, in which food is found after the nor- 
mal period of digestion is over, methodic lavage should be in- 
stituted; in other words, if six or seven hours after a test din- 
ner, or two hours after a test breakfast, coarse particles of food 
are found in the stomach contents, or, above all, if the stomach Lavage super- 
after a late supper preceded bv lavage, contains food particles fluous if motor 

' . power of stom- 

on the next morning, then washing out the stomach contents is ach good 

indicated. Unless the motor power of the stomach is impaired, 
however, lavage of the stomach is altogether superfluous, even 



382 



CARCINOMA OF THE STOMACH 



Time of per- 
forming- lavage 
in impaired 
motor power 



Lavage with 
medicated irri- 
gations 



Symptomatic 
treatment 



Vomiting 



if it is found by analysis of the stomach contents that the pep- 
tic power of the organ is greatly reduced. 

In severe degrees of motor insufficiency, i. e., in those cases 
in which undigested food particles are found in the stomach in 
the morning, lavage should be performed early in the day and 
before the first meal is taken. If the patient cannot sleep on ac- 
count of the gastric distention, belching, pain or vomiting, that 
result from stagnation of the stomach contents, then lavage 
should again be performed immediately before retiring. In the 
milder forms of motor insufficiency, lavage is best done before 
the evening meal, for, in this way, the residue remaining in the 
stomach from the midday meal, and possibly from the morning 
meal, is removed and the supper goes into a clean and empty 
stomach, so that the evening meal can either be properly digested 
or can be propelled into the bowel in time without producing 
nocturnal distress. 

Lavage of the stomach in carcinoma should be continued for 
a long time, best of all, throughout the course of the disease or 
until a gastro-enterostomy is performed or possibly until ulcera- 
tion of a pyloric carcinoma occurs whereby a free passage from 
the stomach into the bowel may become re-established. 

Lavage performed before breakfast or before supper may 
be combined with the injection of stomachics into the stomach; 
or the wash water may be medicated with antiseptics like salicylic 
acid, boric acid, etc. (see page 356). The addition of these rem- 
edies to the wash water is, however, rarely necessary and, in 
most cases, altogether superfluous. 

In most cases of carcinoma of the stomach, if the proper diet 
is administered and lavage of the stomach is methodically insti- 
tuted special medicamentous treatment for the relief of symp- 
toms is, as a rule, not required. 

Vomiting of large quantities of stagnating food material is 
effectually prevented by lavage, especially if the wash water is 
medicated with antifermentative remedies (see page 356). If 
the vomiting is due to gastric hyperesthesia, cocaine adminis- 
tered as described on page 19, or chloroform water in teaspoon- 
ful doses frequently repeated, may be used. Narcotics are rarely 
indicated, and if they are given at all they should be adminis- 
tered by rectum in suppository or enema, or hypodermically. 
The one serious objection to the use of opiates is their tendency 
to produce constipation. If the vomiting is persistent and does 
not yield to lavage and to a simple diet and the above named 
measures, then the stomach may have to be put at rest for a 



Cakcinoma of the stomach 383 

number of days by total abstinence from food, and nutrition 
maintained by rectal feeding. 

Bleeding from the stomach is rarely severe in gastric car- Hematemesis 
cinoma ; it should be treated by administering a bland, non-irri- 
tating diet and by employing all those measures and remedies 
that have been described at length in the Section on Ulcer, on 
page 376. The best remedy of all to stop oozing in ulcerating 
gastric carcinoma is adrenalin chloride administered in ten to 
twenty drop doses of a 1 :1000 solution, at one hour or two hour 
intervals. In severe cases that are particularly intractable, or 
in cases of ulceration by carcinoma, in which the ulcer erodes a 
large blood vessel, total abstinence from food must be insisted 
upon and the patient fed by rectum. Opiates are occasionally 
indicated, especially if there is much stenosis about the pylorus 
with violent peristaltic movements on the part of the stomach; 
for opium possesses the power of reducing or stopping this per- 
istalsis ; its administration, therefore, in these cases aids in estab- 
lishing quiet and contraction of the walls of the stomach. Ex- 
ternally cold should be applied to the epigastrium either in the 
form of an ice poultice, an ice bag or repeated cold cloths. Hot 
applications are contra-indicated if there is much gastric hem- 
orrhage. 

The pain in carcinoma is usually relieved by the application Pain 
of heat to the epigastrium either in the form of hot poultices, 
hot cloths, a Leiter coil through which hot water flows, a ther- 
mophore (see index) or Priessnitz compresses. If the pain 
appears only when the stomach is full, lavage, i. e., removal of 
the irritating stomach contents, brings about relief. Sympto- 
matically the pain may be treated by the administration of co- 
caine (see page 19), by chloroform given in three to five drop 
doses on ice, and if there are signs of peritonitic irritation, by 
opium with atropine, administered hypbdermically, by clysma or 
in suppository. 

The constipation in gastric carcinoma is best treated by Constipation 
enemas of soap and water, glycerin and water, or oil. Laxatives 
are rarely necessary ; if any are employed, simple vegetable rem- 
edies like rhubarb or cascara may be given in the form of tln j 
compound rhubarb pill containing rhubarb, aloes and myrrh and 
peppermint oil in the dose of four to eight grains, or as the fluid 
extract of cascara in half to one teaspoonful doses in water. 
Mercurial purges, drastics or salines should not be administered. 

Diarrhea in carcinoma of the stomach is usually due to the Diarrhea 
entrance of fermenting and decomposing stomach contents into 
the intestine. This fermentative form of diarrhea can gener- 



384 



MOTOR INSUFFICIENCY OF THE STOMACH 



ally be prevented by methodic lavage instituted to remove the 
stomach contents before it undergoes decomposition and enters 
the intestine. If this measure is not carried out, then the intes- 
tinal antiseptics that are discussed in full in the Section on 
Intestinal Catarrh are of use. Very severe diarrheas, finally, 
may have to be combated by the use of opiates. 



Definition 



Motor insufii- 
ciency 



Gastric ectasy 
and dilatation 

Megalogastria 



Gastric atony 



Atonic and 
hypertonic 
gastrectasy 



MOTOR INSUFFICIENCY OF THE STOMACH. (GASTRIC 

DILATATION, GASTRIC ECTASY, GASTRIC 

ATONY.) 

The term motor insufficiency is employed to indicate that 
the stomach cannot get rid of food within the normal time limit. 
This condition may be due to a reduction of the normal propul- 
sive power of the stomach wall, or to the presence of an obstacle 
at the pyloric orifice, or it may be due to an abnormally large 
amount of work imposed upon an otherwise normal gastric 
musculature. Motor insufficiency,^then, primarily designates a 
perversion of function which may or may not be accompanied 
by changes in the size of the organ ; for there may be motor in- 
sufficiency when the stomach is still normal in size but the- 
pylorus is stenosed, or even when, as in some forms of gastric 
carcinoma and in cirrhosis of the stomach wall, the stomach is. 
abnormally small. 

The terms gastric dilatation and gastric ectasy should be 
reserved for those cases of enlarged stomach in which there is 
motor insufficiency. Simple enlargement of the stomach with- 
out impairment of its motor power is designated as megalo- 
gastria. 

Gastric atony means muscular weakness of the gastric walls. 
Wherever there is atony there is also muscular insufficiency and, 
as a rule, but not invariably, gastric dilatation (gastric ectasy). 
Gastric ectasy with atony of the stomach wall is called atonic 
ectasy. There is also a form of hypertonic ectasy in which 
the stomach is large and in which there is motor insufficiency, 
but in which the muscularis is hypertrophic and not atonic. This 
form of hypertonic ectasy occurs particularly in cases of steno- 
sis about the pylorus in which the muscles of the stomach wall 
are submitted to persistent overwork. Sooner or later this form, 
too, develops into atonic gastric ectasy, especially if the obstacle 
about the pylorus is not removed. It will be seen, therefore, 
that gastric atony and gastric dilatation are closely related and 
that the latter may develop from the former. They have this in 
common that both are accompanied by motor insufficiency. 



MOTOR INSUFFICIENCY OF THE STOMACH 385 

For ordinary clinical purposes, the finer anatomic differen- 
tiation between motor insufficiency with ectasy or atony is super- Clinical dif- 
fluous and the following practical method of differentiation eren ia lon 
suffices for therapeutic purposes : 

The stomach is atonic if it requires an abnormally long time 
to expel the food, but, nevertheless succeeds in getting rid of 
all or nearly all of its contents during this abnormally long 
period. As a result little occasion is given for stagnation of the 
stomach contents and for its fermentative decomposition. A 
simple atonic stomach should always be empty in the morning. 
In atony the stomach is only slightly enlarged if at all and its 
lower boundary should not extend further than the umbilicus 
when it is filled (e. g., with a 1,000 cc. of water). The stomach 
is dilated (gastric ectasy) if it always contains food particles in 
the morning and if its lower boundary extends below the umbili- 
cus; here stagnation of stomach contents and fermentative de- 
composition are the rule. 

Inasmuch as gastric ectasy frequently results from and fol- 
lows atony, it is clear that intermediary stages between simple 
atony and atony with dilatation must needs be encountered. 

Gastric atony is often congenital. In most cases, however, Congenital, ac- 
quired atony 
it is acquired and constitutes a part phenomenon of general 

muscular asthenia; thus gastric atony is encountered in many 

chronic cachectic states, after severe infectious diseases, in many 

disorders of the liver, the heart and the kidneys, occasionally 

in chlorosis and anemia, after mental or bodily exertion and 

sexual excesses, after poisoning with alcohol and tobacco and 

in a variety of functional and organic diseases of the central 

nervous system. 

Dilatation of the stomach, on the other hand, may, as men- Causes of dila- 
tioned aboye, develop from simple atony of the stomach superin- tatlon 
duced by any of the above causes, especially in cases that despite 
the weakness of the stomach walls, persist in over-eating and 
over-drinking. In most instances, however, gastric ectasy is due 
to the presence of some mechanical obstacle to the passage of 
food in the pylorus or upper duodenum, as for instance, car- 
cinoma, cicatricial constriction following ulcer or erosion, pyloric 
spasm with or without hypertrophy of the pyloric musculature 
from different causes (see page 408), constriction or obturation 
of the pylorus by adhesions in the neighborhood or from com- 
pression from without by tumors, gall stones, etc. 

It will be seen from all that has been said that the causal Causal treat- 
treatment of motor insufficiency of the stomach with or with- ment 
out gastric atony or dilatation must take all these manifold fac- 
tors into careful consideration. In many instances the primary 



386 



MOTOR INSUFFICIENCY OF THE STOMACH 



Diet 



General con- 
siderations 



Diet with nor- 
mal or in- 
creased H CI 



Diet with Re- 
duced H CI 



No large meals 



cause cannot be removed or can be made to disappear only very 
slowly. In other cases the primary cause may be removed, but 
the motor insufficiency, i. e., the weak condition of the muscles 
of the stomach and enlargement of the organ persist. In all 
these cases active treatment directed towards -improving the 
motor power of the stomach; towards preventing further dila- 
tation and stagnation of the stomach contents ; above all, towards 
maintaining the patient's general nutrition, despite the exist- 
ence of gastric ectasy, must be energetically instituted. 

The diet in all these cases should be of such a character, first, 
that it imposes the minimum of labor on the stomach whose 
motor power is impaired; second, that it can be propelled easily 
and rapidly into the intestine; third, that it contains none of 
the articles that can undergo ready gaseous or acid decomposi- 
tion in the stomach when they stagnate there ; fourth, that it is 
sufficiently nutritious to sustain the patient. In selecting the 
proper diet the state of the gastric secretion must be taken into 
consideration in addition to the degree of motor insufficiency. 
The composition of the food will, therefore, have to vary accord- 
ing to the presence or absence of sufficient or over-abundant 
hydrochloric acid and peptic ferments. 

If the secretion of hydrochloric acid is normal or increased, 
then there is no objection to the use of meats and other albu- 
minous foods, inasmuch as these are promptly digested in the 
stomach; at the same time, especially in hyperchlorhydria, the 
ingestion of amylaceous foods should be reduced ; for the diges- 
tion of the latter is always impeded in hyperchlorhydria, so that 
they are apt to undergo abnormal decomposition when they re- 
main in the stomach in an undigested state for an abnormally 
long time. 

If the secretion of gastric juice is reduced no meats at all 
should be given, but eggs, milk and mnshy, amylaceous foods, 
i. e., gruels, made of milk with wheat flour, rice, barley, tapioca 
or sago, milk toast, vegetable purees, fruit sauces, butter, cream 
and olive oil may be administered. 

Large meals should always be avoided and all of the articles 
enumerated above should be given in small quantities at frequent 
intervals. The amount of food and its consistency depend in 
one important group of cases upon the degree of stenosis at the 
pylorus, and one may say axiomatically that the greater the 
obstacle to the passage of food through the pylorus the smaller 
should be the quantity of food that is administered at a time and 
the softer its consistency. 

From a practical standpoint it is best to experiment some- 
what in each case, i. e., to determine at frequep* intervals by 



MOTOR INSUFFICIENCY OF THE STOMACH 387 

actual removal of the stomach contents after a mixed meal, which 
foods of the different kinds are retained and which are evacu- 
ated from the stomach within the normal time limits. In com- 
bination with such a motility test a study of the state of the Motility test 
gastric secretion may advantageously be made and the selection for Ceding* 
of the diet somewhat regulated accordingly. 

All articles of food that are coarse in texture, that contain N <> coarse 
indigestible parts like tendons, skin, connective tissue, in the 
case of meats ; stems, husks, skins, pips, seeds, in the case of vege- 
tables and fruits, should be altogether forbidden. Carbonated 

beverages that distend the stomach are alwavs bad. Alcoholic Carbonated and 
■ • i o -. t o alcoholic li- 

liquors, solutions of albumoses and peptones, very salt foods, very quors to be 

sweet foods and sugar solutions are forbidden, because they all av0lded 
draw water into the stomach and hence over-burden the organ. 

The total liquid intake should be somewhat reduced. A dry Hquid^iSake 
diet is not, however, advantageous, the claims of certain clini- 
cians to the contrary notwithstanding, for the propulsion of 
semi-liquid and mushy foods is always easier in motor insuf- 
ficiency than the propulsion of a dry stomach contents. There 
is, therefore, no objection to the introduction of small quanti- 
ties of fluid with the meals nor to the administration of a liquid 
diet administered in reasonably small quantities, provided the 
liquids administered are nutritious, i. e., consist of milk, albumen 
solutions, strong soups, for the latter are propelled from the 
stomach as easily as mushy foods and more easily than solid 
foods of equal nutritive value. Too great restriction of the liquid 
intake may lead to a dehydration of the tissues manifesting itself 

by a strong sensation of thirst and theoretically, at least, in se- p^ger of 

. . tetany 

vere degrees of motor insufficiency by tetany. 

Excessive dehydration resulting from great liquid restriction 
that may be necessary in some cases must be forestalled there- 
fore by the administration of fluids by rectum, as described else- 
where, and this procedure is always indicated when the total Administration 
liquid intake is reduced below 1,000 cc. in the twenty-four rectum S y 
hours. In very advanced stages of gastric ectasy with serious 
stenosis, the ingestion of liquids may have to be reduced even 
below this minimum and in such cases rectal administration of 
liquids will have to be instituted several times a day. 

Occasionally total abstinence from food for a few days Occasional to- 
greatly aids in restoring some tone to the stomach; for when stinence 
the gastric walls are spared all labor one may assume that the 
mucularis recuperates under this rest treatment. In such cases 
the patient may be fed for a number of days to great advantages 
by rectum alone. Rectal feeding, too, has a place in many cases Rec t al feeding 
to supplement the insufficient food administration by mouth. 



388 



MOTOR INSUFFICIENCY OF THE STOMACH 



Rest after 
meals 



Position to be 
occupied when 
lying down 



Lavage 



Time for per- 
forming lavage 



In cases of gastric ectasy that are being prepared for operation, 
rectal feeding too may be instituted for several days preceding 
the operation. 

Rest after meals is a very essential element of the treatment. 
If the patient lies down after each feeding a larger proportion 
of blood determines towards the digestive tract than if the pa- 
tient moves about; for, in the latter case much of the blood is 
drawn to the periphery, so that digestion may be somewhat im- 
peded thereby. At the same time the erect position, especially 
when combined with active exercise, determines dragging and 
distention of the stomach when it is full of food and heavy, and, 
in this way, favors the further development of atony and dilata- 
tion. It is best to advise such patients to lie down for half an 
hour or an hour after each meal, preferably on the right side, 
as this facilitates the movements of the food toward the bowel. 
If there is an ulcer at the pylorus and much dilatation of the 
stomach, the latter position may, however, be hard to maintain 
on account of the pain and distress produced by the pressure 
of the food on the ulcerated area. In such cases the dorsal po- 
sition is preferable. The evening meal should never be eaten 
too near bedtime, as digestion is less active during sleep and 
hence food may remain abnormally long in the stomach during 
the night. 

Lavage of the stomach should be instituted in all cases of 
motor insufficiency according to the principles enunciated in a 
preceding section (see page 355). In simple atony without ectasy 
and with mild degrees of motor insufficiency, lavage may occa- 
sionally be dispensed with. In gastric ectasy due either to 
atony or stenosis, lavage, however, is of the greatest value. By 
instituting methodic lavage an attempt is made to re-establish 
physiological conditions ; this applies in particular to those cases 
of motor insufficiency in which food is still present in the stomach 
in the morning; for normally the stomach should always be 
empty at this time and it should enjoy several hours of rest dur- 
ing the night. In order to promote this object the evening meal 
should be taken, as stated above, several hours before retiring, 
preceded by a lavage ; for, in this way any residue that may have 
accumulated from breakfast or dinner will be removed and the 
supper, which should be light, is introduced into a clean stomach 
containing n<5 fermenting food particles. Such a supper should 
be digested within three or four hours. If it is found that the 
stomach contains food particles in the morning, even when this 
plan is adopted, or if the patient suffers much distress at night 
from distention of the stomach with gases, then it may be nec- 
essary to perform lavage before going to bed. In still other cases 



MOTOR INSUFFICIENCY OF THE STOMACH 389 

in which only very little residue is found in the morning, the 
stomach may be washed out before breakfast and again before 
supper. In most cases the afternoon lavage, six or seven hours 
after the heaviest meal, is sufficient. 

Lavage of the stomach should be very thorough and should be Medicated 
performed both with the patient sitting up and lying down. ava S e 
Washing the stomach with anti-fermentative solutions like a 
three per cent, boric acid solution; two pro mille salicylic acid 
solution; two per cent, resorcin solution; two pro mille hydro- 
chloric acid, and other drugs, is occasionally useful. The objec- 
tion advanced against frequent lavage, viz : that nutritious ma- 
terial is thereby removed from the stomach, is more than over- 
balanced by the advantages accruing to gastric digestion from 
the removal of stagnating particles and the introduction of new 
pabulum into a clean, empty stomach. 

In combination with the morning lavage, douching of the Douching 
stomach may be instituted. This consists in forcing through a 
stomach tube containing numerous small openings, water, of 
eighty to ninety degrees Fahrenheit, under considerable pres- 
sure. Water injected into the stomach in this way hardly 
reaches all parts thereof, but the temperature of the water seems 
to exercise a tonic effect upon the weakened gastric muscula- 
ture. This method of treatment is applicable chiefly to cases of 
gastric atony without much dilatation; but in gastric ectasy 
the injection of much water into the stomach under pressure 
is not good. The addition of medicaments to the douche water 
is hardly necessary. Stomachics added to the douche (see page Addition of 
362) if the secretion of gastric juice is reduced and the appetite drugs ,to 
is impaired, can do no harm. If the hydrochloric acid is low 
sodium chloride in the proportion of ten grammes to the litre 
may be used. If there is hyperchlorhydria, a silver nitrate solu- 
tion of the strength of 1 :1000 is useful. 

In order to lend support to the stomach, especially in cases 
in which the abdominal parieties are relaxed, and in general 
gastro- and entero-ptosis combined with gastric ectasy, band- 
aging the abdomen is of some value. Abdominal supporters and Bandaging th» 
bandages hold up the abdominal contents and thereby support abdomen 
the stomach; dragging and tugging on ligaments is prevented 
and consequently various reflex irritations that may react un- 
favorably upon the tone of the stomach walls eliminated. An 
abdominal supporter in order to do any good at all should fit 
correctly. Some cases of gastric dilatation cannot bear abdom- 
inal binders on account of the pressure they exercise upon the 
stomach, especially when it is full or distended with gas. 



390 



MOTOR INSUFFICIENCY OF THE STOMACH 



Electricity 



Technique of 
electro-thera- 
peutics 



Massage of the 
stomach 



To stimulate the tone of the atonic gastric musculature, elec- 
tricity applied in different ways has been used. Personally,. 
I have abandoned its employment, as its administration, espe- 
cially by the intra-gastric method, is rather complicated and 
usually disagreeable, and because nothing can be accomplished 
by the means of electric treatment that cannot be brought about 
equally well or better by other simpler means. In advanced 
stenosis of the pylorus, moreover, in which the gastric wall is 
not atonic, it is not good practice to over-stimulate the gastric 
musculature; for the latter is already working to the limits of 
its powers, as manifested often by the appearance of visible per- 
istaltic waves in the region of the stomach. 

Either the faradic or galvanic current may be used. Static 
electricity is rarely employed. The faradic or galvanic cur- 
rent may be applied either by the percutaneous (extra-gastric) 
method or by the intra-gastric method. If the motor power of 
the stomach is to be stimulated a faradic current applied per- 
cutaneously is the best. It should be applied by means of two 
large sponge electrodes, one of which is laid directly over the 
stomach, the other one about an inch removed from the right 
edge of the first electrode along the right side of the body. The 
current should be strong enough to produce muscular twitchings 
of the abdominal muscles but only very slight pain. The faradic 
current should not be applied in this way for longer than ten 
minutes. For the relief of sensory symptoms the galvanic cur- 
rent applied by the intra-gastric method is the most effective. 
A great variety of gastric electrodes have been described. The 
simplest one is a spiral wire with a knob at the end which can 
be pushed through an ordinary stomach tube. Before applying 
galvanic electricity by the intra-gastric method, the stomach 
should be filled about one-half with water in order to prevent 
burning of its walls by direct contact with the electrode. The 
anode should be connected with the intra-gastric electrode, the 
cathode with a large plate electrode which should be applied over 
the sternum or to the back. A weak current should be used and 
the treatment should not last longer than ten minutes. If the 
intra- ventricular treatments cannot be carried out, then either 
the galvanic or faradic current may be utilized for the relief of 
sensory symptoms by applying one large electrode connected with 
the anode over the epigastrium, another one connected with the 
cathode over the back or sternum. 

In skillful hands massage of the stomach is of some use ; this 
measure, however, is, as a rule, superfluous. It is expected to 
fulfill two objects, namely, to strengthen the musculature of the 



MOTOR INSUFFICIENCY OF THE STOMACH 391 

stomach and to propel the gastric contents onward; the former 
object, owing to the inaccessibility of the stomach is probably 
very difficult to attain and therefore the value of massage in 
this direction is highly problematical. The latter effect is, at 
best, merely palliative and is, self-evidently, altogether fictitious 
and, at best, transitory, unless carried out immediately after 
each meal. There are, moreover, definite contra-indications to 
the use of gastric massage, notably the presence of an ulcer, 
the occurrence of a recent hemorrhage and perigastric adhesions. 

Of general hydr other apeutic measures the Scottish douche, Hydrotherapy- 
i. e., the application of a strong stream of water, the temperature 
of which is changed every twenty or thirty seconds from hot to 
cold, is the most useful. Fan douches, too, are of some value. 
Priessnitz compresses in many cases exercise a soothing effect 
and slightly stimulate contractions of the gastric muscles. 

Of drugs that are used to improve the tone of the gastric Medicamentous 
muscles, tincture of mix vomica or strychnia are the most popu- rea men 
lar. Tincture or extract of mix vomica should be given by mouth 
before meals or in the morning on an empty stomach with the n ux vomica 
stomach douche (see page 363). Strychnine is best given hypo- 
dermically. 

Constipation and vomiting should be treated by the use of 
enemata, mild vegetable laxatives like rhubarb and cascara, and 
by abdominal massage (see index) ; mineral waters are, of course, 
to be eschewed. 

Vomiting generally yields to the proper regulation of the Constipation 
diet and to lavage. Priessnitz compresses or hot poultices to Vomiting 
the epigastrium are frequently of value and if the vomiting is 
due to hyperesthesia of the gastric mucosa, cocaine (see page 
19 ) or narcotics administered in suppositories or hypodermically 
may be used. 

A useful procedure finally, especially in pyloric spasm with 
resulting stenosis and motor insufficiency, is the so-called oil 
cure. It consists in the administration of 50 cc. of oil three 
times a day, half an hour before eating, or of 150 cc. of olive Oil cure 
oil on an empty stomach in the morning, either swallowed or 
administered through a stomach tube. This latter treatment fre- 
quently stops the spasmodic closure of the pylorus, facilitates 
the passage of the gastric contents into the bowel, exercises a 
slight laxative action which effectually counteracts any tendency 
to constipation and, at the same time, aids in nourishing the 
patient. 

Surgical treatment often becomes necessary in advanced de- Surgical treat- 
grees of motor insufficiency. It may consist either in removal of ment 



392 



MOTOR INSUFFICIENCY OF THE STOMACH 



Indications for 
surgery 



Surgical 
methods 



the obstruction at the pylorus, in drainage of the stomach by 
gastroenterostomy, in mechanical reduction in the size of the 
stomach or in producing mechanical changes in the size or the 
position of the stomach. 

The indications for surgical intervention are the following: 

First, the discovery of some mechanical obstruction to the 
passage of the food from the stomach into the intestine, especially 
if this obstruction remains persistent for a long period 
of time or if it increases, or if it is due to a malignant growth. 

Second, if the motor insufficiency, atony and ectasy grow 
worse instead of better, despite the treatment outlined above. 

Third, if despite all treatment and the apparently success- 
cul relief of symptoms, including the motor insufficiency, the 
nutrition of the patient becomes impaired and weight is lost. 

Fourth, if the patient does well under continuous treatment, 
but grows worse as soon as persistent treatment is stopped. In 
such cases, especially if the physician is convinced that the pa- 
tient could not improve unless treatment were continuously car- 
ried out, an operation may become necessary. 

The methods of removing pyloric obstruction by resection, 
pyloroplasty, etc., need not be discussed in this volume. The 
indications for resection of the pylorus in carcinoma have been 
formulated on page 378. In many cases, especially those in which 
the motor insufficiency and dilatation are far advanced, gastro- 
enterostomy is, by all means, the best operation; for in some 
cases even the re-establishment of a patency of pylorus would not 
restore the motor tone to the stomach. Sewing tucks into the 
stomach is a useful procedure only in mild degrees of atony in 
which the stomach muscles still retain some contracting and pro- 
pelling power. Gastroplication, shortening of the gastric- 
hepatic omentum, or of the gastric-hepatic and gastric- 
splenic ligaments, or fixing the stomach in a position 
where drainage through the pylorus becomes better, 
either by stitching or by making a sling of the lesser omentum 
sewed to the pancreas for the stomach to rest on, are methods 
of surgical treatment that have all been tried. All of the latter 
are applicable only to cases of motor insufficiency with dilatation 
due to atony, not to dilatation due to stenosis about the pylorus. 
It is altogether too early to pass definite judgment on the efficacy 
of these different, rather complicated, surgical procedures. 



GASTRIC HYPERSECRETION AND HYPERCHLORHYDRIA 393 



■GASTRIC HYPERSECRETION AND HYPERCHLOR- 
HYDRIA. 

These two conditions may be discussed together although Definition 
they occasionally produce somewhat different symptoms and may 
call for somewhat different treatment. In hypersecretion the 
gastric glands secrete gastric juice in excess when they are stim- 
ulated by the food, but they may also do this when they are not 
stimulated by the food, i. e., when the stomach is empty; con- 
sequently in this condition the stomach contains abundant gas- 
tric juice nearly all the time. Hypersecretion obviously is always 
accompanied by hyperchlorhydria, but the latter condition may 
-also occur as an independent affection without hypersecretion, 
And manifest itself by an excessive out-pouring of hydrochloric 
acid only when the stomach contains food. The two conditions, 
it will be seen, are closely related, the difference between them 
being more of degree than of kind. Hypersecretion may be con- 
sidered as a continuous form of hyperchlorhydria occurring 
without the stimulus of food; hyperchlorhydria as a periodic 
form of hypersecretion and one that requires the stimulus of 
food to be produced. 

Hypersecretion and hyperchlorhydria may be a part phenom- c auses 
-enon of a general neurosis; they may follow mental, emotional 
over-strain or psychic shock; they may occur in the course of 
chlorosis; they may result from abnormal irritation of the gas- 
tric mucosa, if dietetic indiscretions, especially accompanied 
by the abuse of alcohol, tobacco, very hot foods, spiced foods, 
are committed; or they may be seen in anatomic lesions of the 
stomach or may finally constitute a reflex phenomenon emanating 
from remote organs of the body. 

The causal treatment, therefore, of hypersecretion and hyper- Causal treat- 
chlorhydria must take all these elements into consideration. If m e n t 
the patient is a neuropath, then the neurasthenic or hysterical 
•condition should be treated as described in the Section on Gas- 
tric Neuroses. 

All emotional or mental over-strain should be avoided, any 
condition of anemia or chlorosis corrected, bad habits of eating 
improved and all factors that may become operative to irritate 
the gastric mucosa and the secretory nerves of the stomach, either 
directly or by reflex irritation, sought for and, if discovered, re- 
moved. 

Inasmuch as the out-pouring of excessive gastric juice with an The diet 
abnormal amount of hydrochloric acid is in most cases due to 
the stimulating effect of food which in these patients produces a 



394 



GASTRIC HYPERSECRETION AND HYPERCHLORHYDRIA 



Articles to be 
avoided 



Abundant al- 
bumen 



Meats 



Selection of 
meats in pres- 
ence or absence 
of motor in- 
sufficiency 



Starchy foods 



quantitatively abnormal secretory reaction, the selection of the 
proper diet is of paramount importance. The diet, while ade- 
quately nourishing the patient, should be mechanically non- 
irritating, i. e., it should contain no coarse and indigestible par- 
ticles like skin, tendons, cartilages, husks, seeds, pips, etc. It 
should contain no spices or condiments (mustard, pepper, 
paprica, cloves, etc.) ; nor any fruits or vegetables incorporating 
irritating oils (onions, radishes, horse-radish, etc.) ; nor should 
very acid foods, very hot foods, nor strong alcoholic drinks be 
administered. 

The diet should contain abundant albuminous pabulum; for 
the latter, owing to its power to combine with hydrochloric acid, 
acts as an antacid and thereby gives symptomatic relief. The va- 
rious albuminous foods differ in their power to bind hydro- 
chloric acid. 

Best of all among the meats are beef, mutton and raw ham 
(Fleischer), but other forms of meat or fish or poultry are 
suitable food for these cases, provided they are not served in 
the form of cured, spiced or corned meats ; for meats prepared in 
this way, on account of the spices, salts and extractives they con- 
tain, directly stimulate the flow of hydrochloric acid. 

The selection of the meats must also be governed somewhat 
by the presence or absence of motor insufficiency, atony, or dila- 
tation of the stomach. If the stomach does not empty itself with- 
in a normal time (and in hyperchlorhydria it usually empties 
itself more rapidly than normal, especially if an albuminous diet 
is administered), then all coarse varieties of meats should be 
avoided (see page 387). If there is no motor insufficiency, then 
coarse meats are particularly useful, as they require much hydro- 
chloric acid for their digestion and hence possess relatively great 
hydrochloric acid binding properties. 

In hypersecretion or hyperchlorhydria associated with motor 
insufficiency or ectasy, finely divided meat, i. e., scraped or 
hashed meat, milk in small quantities and given at frequent 
intervals, and eggs are the best albuminous foods. Milk, gruels 
and soups made with flour of rice, wheat, barley, or with arrow- 
root, tapioca, sago, eggs ; or milk rendered more nutritious by the 
addition of condensed milk or milk powder (see index) are all 
useful additions to the meat diet. 

Starchy foods are digested with difficulty in the stomach in 
hyperchlorhydria and hypersecretion. This is due to the fact 
that in hypersecretion, free hydrochloric acid is either present, 
when the food enters the stomach or appears there earlier than 
normal in simple hyperchlorhydria, so that it interferes with the 
amylolytic digestion of the starches in the stomach by inhibiting 



GASTRIC HYPERSECRETION AND HYPERCHLORHYDRIA 395 

the action of the saliva that is swallowed. Starchy foods, there- 
fore, unless promptly evacuated into the bowel, undergo abnor- 
mal fermentation and lead to the formation of irritating organic 
acids in the stomach; moreover their digestion in the bowel is 
interfered with as they enter the intestine in an hyperacid me- 
dium that must first be neutralized and rendered alkaline by the 
intestinal juices before the latter can digest starchy pabulum; 
for this reason amylaceous foods should never be given on an 
empty stomach in the disease under discussion and should always 
be given in relatively small quantities together with, or better 
still, after an abundant proteid diet. 

The assimilation of starchy foods is greatly facilitated by Dextrinized 
administering them in a dextrinized, i. e., partially predigested, cart> oliydrates 
form, as malted foods, toasts, zwieback or as dextrose. The lat- 
ter, especially as it is readily absorbed from the gastro-intestinal 
tract, does not stimulate the hydrochloric acid secretion as much 
as other carbohydrate foods, so that the carbohydrate require- Dextrose solu- 
ment of the organism can very well and safely be satisfied by 
the administration of dextrose in ten to twenty per cent, watery 
solution, given at frequent intervals. In atony or ectasy of the 
stomach with stagnation of stomach contents, dextrose solution, 
however, should not be given, especially as it possesses the power 
to some degree of drawing water into the stomach, an event that, 
as stated in a previous section, is to be especially avoided. Cane Cane sugar 
sugar is by far less useful than dextrose, for the former must 
first be inverted into dextrose and levulose before it can be assim- 
ilated, and this process occurs with great difficulty in an acid 
medium, or in a medium that is only slightly alkaline. 

The mode of preparing amylaceous foods is important; the Preparation of 
carbohydrates are best administered in the form of vegetable starch y foods 
purees, mashed or baked potato, fruit sauces or in the form 
of different flours, with milk, as gruels or mushes as described 
above. Raw, stringy, coarse or acid vegetables or fruits, fresh 
or coarse breads, cereals containing husks should be carefully 
avoided. 

Fats never do any harm in hyperchlorhydria and hyperse- Fats 
cretion if given in a digestible form (see page 353) ; butter, 
cream, vegetable oils are all useful foods, whereas the animal 
fats, being less digestible, should be given very sparingly. Cer- 
tain theoretical objections have been formulated against the 
administration of fats. The claim in particular has been ad- 
vanced that they, too, require an alkaline medium for their diges- 
tion in the intestine and that in hyperchlorhydria and hyperse- 
cretion such a medium is not created as soon as it normally should 
be. These objections are overthrown by practical experi- 



,m 



GASTRIC HYPERSECRETION AND HYPERCHLORHYDRIA 



Beverages 



Alkaline min- 
eral waters 



Alcoholic li- 
quors, tea, cof- 
fee 

Smoking 
Small meals at 
frequent in- 
tervals 



Stomach 
should never 
be empty 



Night feeding 
Lavage 

Douching 



ence. The high caloric value of the fat, the empiric fact that 
they are well digested in the intestine and that they are well 
borne, despite the existence of hyperchlorhydria, especially if 
they are administered together with abundant proteid, renders 
them very useful additions to the diet in nearly all cases. If 
there is combined with hyperchlorhydria or hypersecretion an 
advanced degree of motor insufficiency, especially if gastrectasy 
is present, then they should, of course, be given sparingly. 

Fluids, provided there is no gastric atony or ectasy, may be 
given abundantly. They act very well symptomatically by dilut- 
ing the hyperacid gastric juice without interfering with the 
digestion of the albumens. Alkaline mineral water, especially 
the carbonated varieties, are especially useful as table bever- 
ages; for they combine antacid properties with slightly anes- 
thetic powers (C0 2 ) and are consequently particularly useful 
when hyperchlorhydria is associated, as it so often is, with gastric 
hyperesthesia. That carbonated beverages should not be used 
in gastric atony or gastrectasy need hardly again be empha- 
sized. 

Alcoholic liquors, tea and, above all, coffee, should be forbid- 
den, for they all somewhat irritate the stomach and stimulate the 
flow of gastric juice. Smoking, too, is best forbidden altogether. 

Small meals containing abundant proteids, given at frequent 
intervals are better than large meals given at longer intervals. 
If small meals are administered over-secretion of gastric juice 
may often be avoided. It is a very good rule, however, never 
to let the stomach, in these cases, become altogether empty at 
any time during the day. The patient may have a breakfast, 
dinner and supper of moderate volume at the regular times, but 
should, in addition to these three main meals, drink a glass of 
milk or eat a soft boiled egg or two with a cracker or a piece of 
toast in the middle of the forenoon, in the middle of the after- 
noon and on retiring. If patients suffering from advanced de- 
grees of hypersecretion or hyperchlorhydria complain of much 
pain or distress during the night, on account of the presence of 
free hydrochloric acid in the stomach, then a glass of milk taken 
in the middle of the night is often of the greatest value in re- 
lieving this very disagreeable symptom. 

Lavage of the stomach is of relatively small value in hyper- 
secretion and hyperchlorhydria unless there is some motor in- 
sufficiency. In cases that suffer from nocturnal distress, as 
described above, washing out the stomach with a dilute alkaline 
solution just before retiring is, however, often of value. 

Douching the stomach (see index), after a cleansing lavage 
in the morning, with a 1:1000 silver nitrate solution or a two 



GASTRIC HYPERSECRETION AND HYPERCHLORHYDRIA 397 

per cent, boric acid solution is also often of some value. 100-200 Silver nitrate 
cubic centimeters of the silver nitrate or boric acid solution are Boric acid 
left in the stomach for two to five minutes and then washed 
out with water. The silver nitrate, in particular, seems in some 
cases to reduce the secretion of gastric juice for the rest of the 
day; at the same time it acts somewhat as an anesthetic to the 
irritable gastric mucosa, so that the silver nitrate treatment is 
of especial value in hyperesthesia of the stomach. 

Of other remedies that can suppress the secretion of gastric Remedies to 
juice, belladonna and atropine are the most important. The excretion 
former given as the extract in combination with an alkali is Belladonna 
often of signal value. The following prescription is useful: Atropine 

Extract of Belladonna, 0.03 gm. 

Burnt magnesia, 0.5 gm. 

M. Fifteen such powders. 
Sig. One three times a day after eating. 

(Ortner.) 

Atropine is best given hypodermically in doses of from one 
hundredth to a fiftieth of a grain, once a day, in the morning. 

Alkalies are, as a rule, indispensable in the treatment of A-lkalies 
hyperchlorhydria and hypersecretion. The chief object of ad- 
ministering them is to neutralize the excessive hydrochloric acid 
that is poured into the stomach. In order to be effective they 
must be given in large doses after meals, at the period when 
digestion is at its height. In hypersecretion it may be necessary 
to give them also when the stomach is empty, i. e., before eating 
or in the middle of the night in order to neutralize the acid that 
is present at that time. Sodium bicarbonate is the most popular Sodium bicar- 
alkaline remedy, but it should be used with some care as it is 
slightly irritating to the mucosa. The copious development of 
carbon dioxide is generally distressing to the patient on account 
of the gastric distention and belching it produces and may even 
be dangerous in ulcer. The sodium chloride that is formed, 
moreover, somewhat stimulates the secretion of hydrochloric acid. 
It will be seen, therefore, that the popularity of sodium carbon- 
ate is not deserved. 

Far better as antacids are magnesia usta or magnesium Magnesia usta 
carbonate. Magnesia usta is probably the best remedy of all, carbonate 
for it is non-irritating to the stomach, it is capable of binding 
nearly four times as much hydrochloric acid as an equal bulk 
of sodium carbonate, and the magnesium chloride that is formed 
does not stimulate the hydrochloric acid secretion in the stomach. 



398 



GASTRIC HYPOSECRETION AND ACHYLIA GASTRICA 



Sodium bibo- 
rate 

Calcium car- 
bonate 

Alkaline and 

alkaline-saline 

waters 

Benefits of re- 
sort treatment 



Magnesia usta, moreover, possesses the power of binding any 
C0 2 that may be formed from fermentation in the stomach, and, 
finally, magnesia salts possess slightly laxative properties that are 
useful in order to counteract any tendency to constipation. 

The following mixture of sodium carbonate and magnesia 
especially is very useful and answers all purposes in practice: 

Sodium carbonate, 

Burnt magnesia, of each, 100 parts 

Sugar of milk, 150 parts 

This mixture should be procured in bulk by the patient and 
should be taken in half to one teaspoonful doses, in milk, at the 
height of digestion. 

Another good preparation is a compressed tablet containing 
equal parts of sodium carbonate and magnesium carbonate. 
The administration in a compressed tablet favors slow solution 
of the alkalies in the stomach and hence somewhat prolongs their 
effect. Moreover, this mixture leads to a very slow evolution of 
carbon dioxide. Other antacids that can be used are biborate of 
soda and calcium carbonate in the form of precipitated chalk, 
given in a third of a teaspoonful dose at the proper times. 

Carbonated alkaline waters (see above) and also saline waters 
are of considerable value in the treatment of hypersecretion 
and hyperchlorhydria. These waters are especially efficacious 
when taken at certain watering places or resorts ; but a great part 
of the good effect observed from their use must be attributed to 
the careful regime that the patients follow at these resorts, to 
the respite from every-day cares and worries, to the agreeable 
psychic stimulus and suggestive effect that is granted when they 
visit these watering places. The successful management of their 
cases, moreover, by resort physicians, who have much experience 
with this particular class of invalids plays an important role. 
The different waters administered at home are certainly less 
effective than when they are taken at watering places. 



Causes 



GASTRIC HYPOSECRETION AND ACHYLIA GASTRICA. 

The reduction or the complete suppression of the gastric juice 
may be a part phenomenon of a general neurasthenia or hysteria, 
or a symptom of various organic diseases of the stomach (carcin- 
oma, chronic gastritis, atrophy, amyloid degeneration), or it may 
attain the dignity of an independent neurosis. Simple hypo- 
acidity or anacidity are probably never seen. In most cases the 



GASTRIC HYPOSECRETION AND ACHYLIA GASTRICA 399 

secretion of the gastric enzymes, too, is reduced, so that it is more 
proper to speak of hypochylia and achylia. 

The most important element in the treatment of hypochylia Diet 
and achylia gastrica is the selection of the proper diet. The 
regulation of the food is dependent on the presence or absence 
of motor insufficiency. If the motor power of the stomach is 
good, then every effort should be put forward to maintain it 
so, and all coarse and indigestible foods, large meals, large quan- Presence or 

flbSGHCG of 

tities of liquid should be avoided as a prophylactic measure. mo tor insuf- 
The patient, therefore, should receive small meals at frequent ncienc Y 
intervals, consisting of easily digestible meats, abundant carbo- 
hydrate and considerable quantities of fat. If the motor power 
of the stomach is impaired, especially if there is in combination 
with hypochylia and achylia gastrica some gastric atony or 
gastric ectasy, then the motor insufficiency becomes the more im- 
portant element to be considered and it should be treated as de- 
scribed in a previous section. 

Provided the motor power of the stomach is good or only Tne motor 

power is srood 
slightly impaired, then meats should be allowed. In selecting the 

kind of meat, its digestibility should be considered above all 
things (see table on page 349), consequently broiled or stewed 
poultry, certain varieties of fish, raw, rare, scraped or hashed 
beef, mutton or ham, calves' brains, sweet-breads, all finely 
divided and carefully freed from skins, tendons, etc., and ad- 
ministered in small quantities, are permissible. 

If the motor power is seriously impaired, meats are best er^is^mpaired'" 
avoided altogether, or, if given at all, administered in very small 
quantities; for one must realize that in the condition under dis- 
cussion the digestion of albuminous pabulum in the stomach is 
very decidedly impaired or altogether inhibited; consequently 
serious harm can be done to the stomach unless the gastric con- 
tents can promptly be propelled into the bowel where the dis- 
assimilation of the albumens can be vicariously carried on by 
tryptic digestion. In certain cases in which the motor power is Pancreas 
not too seriously impaired, pancreas preparations can to advant- 
age be administered together with small quantities of meat ; for in 
this way intestinal digestion is begun in the stomach and the 
disassimilation of the albumens aided. If there is some hydro- 
chloric acid secretion, the pancreas preparations must, of course, 
be given with sufficient alkali to more than neutralize the gas- 
tric hydrochloric acid. 

What has been said of meats applies with equal force to other ^SS S , ^ llk > 

^ vegetables 

albuminous foods, i. e., eggs, vegetables rich in albumen and Albumens 

milk. Eggs should be given in a semi-liquid form or finely divid- 
ed, i. e., either soft boiled, or poached or as scrambled eggs, or 



400 



GASTRIC HYPO-SECRETION AND ACHYLIA GASTRICA 



Carbohydrates 

Fruits and 
vegetables 



Fats 



Delicacies 



Alcoholic bev- 
erages 



Lavage 



Douching 



as chopped up hard boiled eggs. Vegetables should be given as 
purees. Milk must be given in small quantities only; for the 
ingestion of abundant fluid, as stated above, is to be avoided. In 
allowing milk the tolerance of the individual for this food must 
always be determined by experiment, for by some patients with 
hypochylia and achylia gastrica milk is not well borne. 

Inasmuch as the digestion of the carbohydrates is in no way 
impaired in hypochylia and achylia gastrica, they should con- 
stitute the major portion of the diet. 

The same rule in regard to the avoidance of coarse, bulky 
and indigestible ingredients applies to the administration of 
vegetables; i. e., vegetables and fruits should be given in finely 
divided form, preferably as purees or fruit sauces and in small 
quantities after a careful removal of all coarse and indigestible 
stems, husks, seeds, pips, etc. Many starchy vegetables like rice,, 
barley, sago, tapioca, arrow-root, wheat and oatmeal flour, etc., 
are best given with milk as gruels or mushes. Toast, bread, zwie- 
back and crackers are all useful and permitted. 

Fats, especially butter, cream, cocoa and vegetable oils are- 
allowed. Animal fats like bacon, lard and suet are less digestible 
than milk and vegetable fats and should consequently be given 
sparingly. Very large quantities of fat should never be given on. 
account of the possible formation of irritating decomposition 
products. Moreover, large quantities of fat rapidly produce a 
sense of satiety and hence often impair the appetite and prevent 
the patient, whose albumen ration is reduced, from ingesting 
sufficient nutriment to maintain adequate nutrition. 

In this class of cases many delicacies, spiced and salted foods,, 
meat extracts, albumose and peptone preparations have a place 
in the menu ; for all these preparations slightly irritate the gas- 
tric wall and stimulate the flow of gastric juice. For the same 
reason small quantities of alcoholic beverages, either brandy or 
whisky with water, a little champagne, a light Moselle, Bur- 
gundy or claret are useful. 

Lavage of the stomach is rarely necessary unless there is, at 
the same time, an advanced degree of motor insufficiency. If 
the motor power of the stomach is impaired, then the same in- 
dications for lavage exist as in any other form of motor insuf- 
ficiency. 

Douching the stomach with a 1 :100 salt solution is in some 
cases a very useful procedure if persistently carried out ; for the 
injection of salt into the stomach in this way seems to exercise 
a stimulating effect upon the secretion of hydrochloric acid. 
Douching with salt solution is best performed early in the morn- 
ing before breakfast or after a cleansing lavage. Many of the- 



GASTRIC NEUROSES 401 

saline waters, taken in small quantities on an empty stomach, Saline waters 
answer the same purpose. 

The use of medicines to stimulate the flow of hydrochloric Drugs 
acid and of gastric enzymes is theoretically indicated, but prac- 
tically very problematical. The administration of small quanti- 
ties of sodium bicarbonate before meals is claimed to be an effi- Sodium bicar- 
cient means of stimulating a reactive flow of hydrochloric acid. me als 
This effect, however, is very doubtful (see page 362). Hydro- 
chloric acid given in small quantities, together with one of the Hydrochloric 

stomachics before meals, is fullv as useful (see page 361). The _, . . 

c Stomachics 

use of hydrochloric acid even in large quantities after meals, or 
the use of peptic enzymes, is of doubtful utility as a substitution 
therapy. If the motor power of the stomach is good the arti- Enzymes 
ficial ingestion of these gastric products is at least superfluous, 
because the intestine vicariously assumes peptic digestion ; in 
fact, in such cases the administration of large quantities of 
hydrochloric acid by reducing the alkalinity of the intestinal 
juices may somewhat retard tryptic digestion. If the motor 
power of the stomach is impaired, then lavage and other measures 
that have been discussed in the Section on Motor Insufficiency 
are far more effective than the use of hydrochloric acid and 
pepsin. 

In the purely neurotic form of hypochylia and achylia gas- Neurotic form 
trica, a variety of hydriatic measures, massage, electricity, the 
selection of a proper climate and resort and, to some extent, sug- 
gestive treatment are all useful. For all these methods, their 
exact indications and employment 1 refer to the next Section. 



II. GASTRIC NEUROSES. 

To the category of gastric neuroses in the broader sense be- 
long certain functional disturbances of the stomach that are pro- 
duced by lesions of the stomach itself, but in which a marked 
disproportion exists between the organic cause and the functional 
effect, indicating that some perversion must exist about the 



Definition and 
causes 



nervous apparatus governing the function that is perverted and stomach^e- 

causing it to react abnormally to a stimulus that, in a healthy sions 

subject, would produce a (quantitatively) different reaction. 

Gastric neuroses proper, however, occur without any anatomic 

changes about the stomach. In most cases they are of reflex 

origin and superinduced bv irritation of the gastric nerves from Without ana- 

° tomic stomach 

some remote diseased organ. In this class of cases, as well as lesions 

in the first mentioned group, the stomach nerves must again be 

considered to be in an abnormal state of irritability. The two 



402 



GASTRIC NEUROSES 



Reflex causes 



Psychic causes 



Intoxications 



Neuropathic 
disposition 



Difliculty of 
rendering the 
diagnosis 



Motor secretory, 
sensory, neu- 
roses 



groups differ merely in this, that in the first reflex irritation 
emanates from some intra-gastric source, whereas in the second 
category the primary focus of reflex irritation lies outside of 
the stomach ; thus eye-strain, certain organic lesions of the brain, 
the cord, the meninges, disorders about the sexual sphere, intes- 
tinal parasites, violent pain anywhere in the body, as for instance 
renal or hepatic colic, angina pectoris, peritonitic pain from dif- 
ferent causes, etc., may all produce gastric neuroses. 

In a third group of cases psychic causes, mental and emo- 
tional disorders, sudden emotional shock, depression, anger, fear, 
mental over-work all react on the innervation of the stomach and 
produce a variety of functional disorders. 

Finally, various intoxications as from lead, alcohol, mor- 
phine, tobacco ; infectious toxemias, notably in tuberculosis and 
malaria; different forms of self -poisoning as uremia, acidosis, 
may all produce functional gastric disorders that have no ana- 
tomic substratum in the muscular, sensory or glandular appa- 
ratus of the stomach. 

All these factors, as already indicated above, cannot, how- 
ever, operate to produce gastric neuroses unless there exists as 
a basis a neuropathic disposition which may be either congenital 
or acquired. The diagnosis, therefore, of a gastric neurosis 
should never be made from negative evidence alone, i. e., on the 
ground that no anatomic gastric disorder is discoverable, but 
it should only be arrived at if to this negative evidence is added 
the positive discovery of general neuropathic stigmata in the 
afflicted subject. • 

It is clear, therefore, that the diagnosis of a gastric neuro- 
sis should always be made with the greatest conservatism. It 
is probably never altogether positive but generally tentative 
and preliminary; for, in many cases, one must realize that the 
discovery of an anatomic basis is impossible merely on account 
of the deficiency of our methods and on account of lack of skill 
or thoroughness on the part of the physician. To determine 
definitely that an individual is a neuropath is a very precarious 
undertaking. In all patients who are not frank neurasthenics 
or hysterics the dyspeptic symptoms of an incipient tuberculosis 
or chronic uremia or intestinal toxemia, gastric disorders occur- 
ring in the presence of adhesions about the stomach (and intes- 
tine) are consequently often grossly misinterpreted. Gastric 
neuroses pure and simple, I believe to be really quite rare, and 
the diagnosis gastric neurosis or nervous dyspepsia is often 
merely a cloak for ignorance or carelessness. 

Neurotic disorders of the stomach may affect either the 
motor, the secretory or the sensory apparatus of the organ, in- 



GASTRIC NEUROSES 403 

eluding the sensation of appetite. For the sake of clearness neu- 
rotic disturbances affecting these different spheres may be dis- 
cussed separately. It is important to realize, however, that 
perversions of several functions are, as a rule, associated, that 
in most cases perversions of single functions alternate. This 
alternation of functional disorders about the motor, secretory 
and sensory apparatus of the stomach, as well as the fact that 
the subjective distress of the patient is, as a rule, out of pro- 
portion to the severity of the functional disorder that is ob- 
jectively determinable, may be considered to some extent char- 
acteristic of all gastric neuroses. 

Chief among the motor neuroses are spasm and insufficiency Motor neuroses 
of the cardia and of the pylorus, hypermotility and peristaltic 
unrest of the stomach, nervous vomiting, nervous belching and 
gastric atony ; among the secretory neuroses hypersecretion and 
hyperchlorhydria, hyposecretion and nervous achylia gastrica; Secretory neu- 
among the sensory neuroses, gastric hyperesthesia, gastralgia roses 

and, in a broader sense, nervous dyspepsia, so-called; in the Sensory neu- 
roses 
latter condition no motor or secretory perversions of the 

stomach are discoverable, but the patients complain merely of 

a great variety of disagreeable subjective sensations during and 

after eating. Perversions of the appetite, finally, manifesting Perversions of 

themselves as anorexia, akoria and bulimia may also be included the a PP etlte 

under the category of sensory neuroses. 

The treatment of all these forms of gastric neuroses con- Correction of 
sists primarily and chiefly in correcting the underlying neuro- neurotic taint 
pathic taint, that is, in restoring normal tone, normal equi- 
librium to the nervous system at large, in re-establishing cen- 
tral autonomy, if it is lost; and in addition any lesion that may 
be considered a cause for reflex irritation of the gastric nerves 
either in the stomach or in other organs (see above) must be 
sought for and, if possible, removed. 

The methods at our disposal for curing the neuropathic taint 
are largely psychical and physical. The element of suggestion, 
education and moral suasion enters largely into this treatment ; 
while rest, hydrotherapy, the selection of a proper climate and 
resort, massage and, to some extent, electricity are all important 
adjuvants to the treatment. Medicines play a very subordinate 
role. 

In addition certain special methods of treatment may have 
to be instituted that are intended to relieve certain symptoms. 

In order to avoid endless reiteration, the general treatment treating the 

of the neurotic individual that is indicated in all forms of gas- n f u . r , oti ^ in ~ 

dividual 
trie neuroses may be discussed first, and the special treatment 



404 



GASTRIC NEUROSES 



Institution and 
resort treat- 
ment 



Simple hydro- 
therapy at 
home 



Hot baths 



Wet, cool pack 



Priessnitz com- 
presses 



Half baths 



that is useful in the different gastric neuroses, later, under sepa- 
rate headings. 

Most cases of gastric neuroses do best, by far, when treated 
either in an institution or at a resort. In. the latter case the 
good effects result from a change of scene, from temporary free- 
dom from worry, excitement and business cares and the attend- 
ance of skillful medical men who are specialists in the treatment 
of these cases, because they see so many of them. The feeling, 
moreover, that something definite is being done exercises both a 
restful effect on irritable nerves and, at the same time, a strongly 
suggestive effect, the value of which, in these patients, cannot 
be overestimated. In most resorts, moreover, and this applies 
also to sanitaria, the various hydrotherapeutic and electric 
treatments, massage and proper dietetic measures can all be 
carried out much better than at home. 

If the patient cannot or will not enter a sanitarium or go 
to some resort where good institutional facilities are available, 
the following simple hydrotherapeutic measures, which can be 
pursued at home, may be of considerable benefit : 

Simplest of all is immersion in a bath of about -95° F. The 
patient should remain perfectly still in the water for about five 
minutes. The temperature of the water slightly below the body 
temperature exercises a distinctly soothing influence. After 
the bath the patient should be dried with a rough towel and the 
surfaces of the body rubbed with alcohol. The patient should 
then be put to bed between woolen blankets and should lie there 
for an hour or two. This treatment may be applied every day 
either early in the morning or late at night before retiring. 

Or the patient may be wrapped in a cloth wrung out of cool 
water of room temperature and the surfaces of the body ener- 
getically slapped and kneaded through the wet sheet. After 
the treatment the patient's body should again be rubbed dry 
with a rough towel, treated with alcohol, after which he is put 
to bed between woolen blankets as above. Or a large Priessnitz 
compress may be applied as follows: The patient is wrapped 
in a sheet wrung out of water of body temperature, the wet 
sheet is covered with a dry sheet and a flannel blanket. In this 
compress the patient remains for one or two hours by which 
time slow evaporation of water has occurred and the first sheet 
will usually be found to be perfectly dry. The patient is then 
given a massage with cocoa butter and again kept in bed for 
an hour or two between woolen blankets. 

A very useful measure, finally, are half baths. The patient 
should sit down in a bath tub containing water of 80° to 90°. 



GASTRIC NEUROSES 405 

The water should reach to the umbilicus. An attendant pours 
water of the same temperature as the bath water over the back 
and shoulders of the patient; and at the same time he ener- 
getically rubs the back and arms, while the patient himself 
rubs his chest and sides. The temperature of the water that is 
poured over the patient may be gradually cooled off. This half 
bath may to advantage be followed by a spray douche, the tem- 
perature of which is gradually cooled. The patient is then 
rubbed dry with a rough towel^ and the surface of the body 
treated with alcohol and the patient put to bed between blank- 
ets as above. 

A very simple measure that the patient can carry out him- 
self is to fill two basins with water, the one with water of about 
100°, the other with cold water. Into each basin a large sponge Spinal spong- 
is placed. The patient sits on the edge of the bath tub and in S 
alternately places the sponge filled with hot and cold water on 
the nape of the neck and squeezes it out so that the water runs 
down the back into the bath tub. Hot and cold water are, in 
this way, alternately applied about ten times. The patient 
then rubs his back thoroughly with a Turkish towel until a 
glow is felt. 

In institutions many other hydrotherapeutic means can be 
employed that require special facilities so that they need not 
be described in this place. 

Massage should be performed only by an expert and it is M assaee 

unnecessary to describe the technique in this volume. The effect 

of general massage is soothing to the whole nervous apparatus 

and when combined with rest is one of the most efficient means 

to quiet hyperirritable nerves, to correct irritable weakness of 

the nervous system at large or of certain nervous areas. 

The soothing effect of massage can be enforced bv general _ ,. .. 

& ^ J & Faradization 

faradization, by the faradic Bath or by combining massage with 

the full bath or half bath or the application of large Priessnitz 
compresses. The best time for administering massage, in most 
cases, is either early in the morning or in the evening before 
retiring. 

Many patients suffering from gastric neuroses of various Weir Mitchell 
organs do very well under a Weir Mitchell fattening cure. This cure 
consists largely in over-feeding the patient with a nutritious, 
assimilable diet administered at frequent intervals. In order 
to be properly carried out the patient should be sent to an in- 
stitution where he can be isolated and wmere, above all, he is 
removed from sympathetic friends and relatives; -where abso- 
lute rest can be enforced, and massage and hydrotherapeutic 
means can be scientifically administered. In addition, the sug- 



406 



GASTRIC NEUROSES 



Dangers of ex- 
clusive milk 
feeding 



Proper diet 



Heat to the 
epigastrium 



Constipation 



Diet schedule 



gestive effect of such a treatment should never be underesti- 
mated. The personality of the physician and of the attendants 
in an institution and, in many cases, firmness to the verge of 
severity, are very important elements in the treatment. 

An exclusive milk diet is not only unnecessary, but may even 
become harmful, because most cases soon acquire a violent dis- 
taste to this monotonous feeding; because the ingestion of such 
large quantities of liquid may be detrimental in certain forms 
of gastric neuroses; and because an exclusive milk diet gener- 
ally leads to very obstinate constipation. It is impossible to* 
designate a diet that applies to all cases. It is necessary, gen- 
erally, to individualize and to arrange a dietary somewhat ac- 
cording to the neurosis that the patient is suffering from.. 
Broadly speaking, fats and carbohydrates should predominate- 
and only enough albumen should be given to satisfy the nitro- 
gen requirements of the patient. 

The appearance of dyspeptic symptoms does not necessitate 
discontinuing the treatment, especially if they appear on the 
first day or two, for they usually disappear if the treatment 
is carried out for a few days consecutively. 

The application of heat to the epigastrium before each meal 
and during the meal, sometimes continuously, often prevents 
or stops disagreeable subjective symptoms about the stomach. 
The constipation, that not uncommonly supervenes, is best coun- 
teracted by increasing the ration of fruit sauces, fresh vege- 
tables and fats or by adding bran with some cereal, cream and 
sugar to the diet. In most cases it will be necessary in addition 
to give soap-suds enemata every few days, which may be medi- 
cated with a little glycerin or, if there is much flatulency, with 
a few drops of turpentine. A little rhubarb or cascara every 
day can do no harm. The administration of large doses of 
calomel, which for a long time constituted a popular routine 
measure in instituting a Weir Mitchell treatment is to be con- 
demned as unnecessary and, in some cases, directly harmful. 

The following dietetic schedule approximately illustrates the 
character of the diet that the patient should receive when under- 
going a Weir Mitchell fattening cure: 

First meal. 7 a. m. 250 cc. of milk-cream mixture* or 
of cocoa made with equal parts of milk and water, three crack- 
ers. 

Second meal. 9 a. m. A cup of beef, mutton or chicken 
broth, twenty-five grammes of scraped beef with butter and 
salt, two pieces of toast with plenty of butter. 

*Two-thirds milk; one-third cream; a teaspoonful of lime water. 



GASTRIC NEUROSES 407 

Third meal, 11 a. m. 200 cc. of egg-nog, two pieces of zwie- 
back with butter. 

Fourth meal. 1 a. m. A cup of broth with rice or barley, 
50 to 60 grammes of roast, stewed or boiled meat, poultry or 
fish, two baked or boiled potatoes or their equivalent in mashed 
potatoes, a dish of some stewed vegetable, a large saucer of apple 
sauce or preserves. 

Fifth meal. 3 p. m. A glass of egg-nog with two crackers. 

Sixth meal. 6. pm. Twenty to thirty grammes of cold meat 
or poultry, two slices of toast and butter. 

Seventh meal. 8 p. m. 200 cc. of milk-cream mixture, two 
crackers. 

Eighth meal. 10 p. m. A glass of egg-nog with two tea- 
spoonsful of brandy and two crackers. 

Many patients assert that they cannot take this quantity of 
food. If strenuous objections on the part of the patient are 
encountered, they may have to be fed by means of a nasal 
catheter. If artificial feeding of this kind must be resorted to 
for the first few days, then, of course, a liquid diet must be 
given. A little firmness on the part of the physician, however, 
will usually succeed in overcoming the objections of the patient. 

After two or three weeks of this treatment the patients usu- 
ally fare better if they are allowed a little exercise, and can go Exercise 
out into the fresh air for an hour or so once or twice a day. The 
duration of this Weir Mitchell fattening and rest cure should 
vary from three to six w T eeks according to the improvement man- 
ifested in the patient's condition. 

MOTOR NEUROSES. 

Hypermotility of the stomach and peristaltic unrest of Hypermotility 
purely nervous origin are rare. These motor manifestations J£y e g® r 
may be considered as a spasm of the whole gastric musculature. 
Aside from treatment directed against the underlying neuro- 
sis, all irritation of the gastric mucosa by coarse and indiges- 
tible foods, by very hot or very cold, spiced or alcoholic ar- 
ticles, should be carefully avoided. The diet should be bland 
and non-irritating and should not distend the stomach by its 
bulk or by the formation of gases. The use of sedatives or 
narcotics, bromides, opiates, belladonna, atropine or hyoscyamus 
will rarely become necessary. 

Spasm of the cardia is also rarely a primary neurosis, but Spasm of the 
generally accompanies various organic disorders of the esoph- cardia 
agus, the cardiac orifice or the cavity of the stomach. It may, 
therefore, be merely a symptom of a variety of causes that must 
be carefully sought for and removed as described in other sec- 
tions. It may, however, be a primary neurosis and if this is the 
case it is usually associated with hyperirritability of the esoph- 



408 



GASTRIC NEUROSES 



Spasm of the 
pylorus 



Nervous belch- 
ing 



agus. Here, again, therefore, the ingestion of food and drink 
that may irritate the esophageal museosa, either mechanically, 
chemically or thermically, must be avoided as a prophylactic 
measure. The insertion of sounds of gradually increasing cal- 
ibre and . leaving these sounds in place is the best method of 
treating cardiospasm, provided no organic lesion about the 
cardia of an ulcerative character contra-indicates the use of 
bougies. In extreme cases the above mentioned sedatives and 
narcotics administered hypodermically or in suppository, com- 
bined with complete abstinence from food for several days and 
rectal alimentation, may become necessary. 

Spasm of the pylorus is almost always due to some intra- 
gastric irritation. The neurotic character of pyloric spasm is 
problematical in any case. If no determinable cause like ulcer, 
hyperchlorhydria or some mechanical lesion about the pylorus 
is discoverable, and if symptoms of pyloric spasm (pain, in- 
creased gastric peristalsis, vomiting) appear when food that is 
irritating by its texture, temperature or mechanical constitu- 
tion enters the stomach, then the existence of an increased 
pyloric sphincter reflex, i. e., pyloric spasm of neurotic origin, 
may be suspected. In an overwhelming majority of cases, how- 
ever, some organic disorder or secretory perversion about the 
stomach will be found. 

The treatment consists in the removal of any mechanical or 
organic condition about the stomach that may be incriminated 
with causing the spasm, and in correcting the underlying neu- 
rosis, in the neurotic type. The treatment in all cases should 
concern itself with removing or counteracting any accompany- 
ing hyperchlorhydria. In extreme instances, again, sedatives 
and narcotics may have to be used. The bougie treatment of 
pyloric spasm has been variously attempted, but this mechanical 
means of treatment is manifestly a procedure accompanied by 
such immense technical difficulties and uncertainties that it is 
hardly to be considered practical. 

Nervous belching is in most cases an hysterical phenomenon 
due to the swallowing of air. The treatment is largely psychic, 
i. e., educational. Very often persistent attacks of nervous eruc- 
tation can be stopped, like hiccup, by suddenly frightening 
the patient. In other cases the patient should be ordered to 
breathe with the mouth open for half an hour two or three 
times a day. This exercises a pronounced psychic effect and, at 
the same time, prevents the patient from swallowing the air, at 
least during the periods of mouth-breathing, and hence prevents 
eructation. If there is much distention of the stomach with 
air (pneumatosis), passing the stomach tube brings prompt re- 



GASTRIC NEUROSES 409 

lief. v If there is any doubt in regard to the character of the 
belching, a fermentation test with the stomach contents will 
quickly tell the tale. 

Aside from the suggestive treatment and general measures 
directed towards the neurasthenic and hysteric state, bromides, 
belladonna and atropine, and in some cases, especially in pro- 
nounced pneumatosis, the hypodermic use of morphine, may be- 
come necessary. Silver iodatus, in doses of a sixth of a grain 
(0.01) after eating, and strychnine in one-thirtieth to a six- 
tieth of a grain doses also after eating, are recommended. 

The diet should, of course, contain no carbonated beverages 
and the minimum of articles that can undergo gaseous fer- 
mentation in the stomach should be allowed; for the develop- 
ment of gas in the stomach by producing real eructations may 
by suggestion start an attack of nervous belching. 

Nervous vomiting, in a broad sense, includes vomiting orig- Nervous vom- 
inating from reflex irritation from the sexual sphere, from float- itin & 
ing kidney, from diseases of the brain and cord, from colic in 
the liver or the kidneys, from peritoneal irritation and from 
the pregnant uterus. Here the treatment of the underlying 
cause and the correction of a nervous predisposition, that must 
be assumed to exist in all cases becomes necessary. In every 
case of nervous vomiting, the gastric irritability should be re- 
duced. In severe cases the patient should remain in bed, should 
abstain altogether from food for a few days and should be 
allowed to swallow only teaspoonful doses of ice cold drinks like 
milk, tea, champagne, or ice pills. No definite dietetic regulations 
can be formulated in the neurotic type of vomiting. Of drugs 
morphine, codeine and belladonna hypodermically or in sup- 
pository are the best. Morphine may be given in doses of an 
eighth of a grain in combination with a two-hundredth of a 
grain of atropin hypodermically, once or twice a day; codeine 
or codeine phosphate in doses of half a grain (0.03) hypoder- 
mically, once or twice a day; or opium and belladonna in sup- 
positories containing half a grain (0.03 gm.) each of the extract 
of opium and the extract of belladonna and administered once 
or twice a day. 

Other remedies that are occasionally useful are chloroform 
given in the dose of three to five drops on sugar or in teaspoon- 
ful doses of ice cold chloroform water; menthol in ethereal solu- 
tion (1 to 10) in the dose of five to ten drops three times a day; 
chloral hydrate in a solution of one part to ten parts of water 
may be given in fifteen drop doses in a teaspoonful of ice water 
every two or three hours. Bromides and chloral nitrate, ten 
to twenty grains each, may be given by rectum. 



410 



GASTRIC NEUROSES 



Pyloric insuf- 
ficiency 



Regurgitation 
and rumina- 
tion (insuffi- 
ciency of the 
cardia) 



Neurotic atony 



Lavage is generally superfluous in these cases. Douching with 
silver nitrate in 1 :1000 solution, or simple irrigation of the 
stomach, is occasionally useful. In employing lavage or douch- 
ing the suggestive effect exercised by passing the stomach tube- 
is generally more helpful than the procedures themselves. 

Pyloric insufficiency is usually due to mechanical causes oper- 
ating either to interfere with the closure of the pyloric sphinc- 
ter (cicatrization, ulceration, etc.) or leading to abnormal 
stretching of the pyloric ring. Nervous cases of pyloric insuf- 
ficiency due to paralysis 'of the motor nerves supplying the 
sphincter are seen in hysteria and in certain diseases of the 
spinal cord. The neurotic form is exceedingly rare and should 
only be diagnosed if the organic form can be definitely excluded. 
In the organic variety the treatment is exclusively causal, in 
the nervous form, it is directed towards correcting the general 
neuropathic taint, and local treatment has no effect. 

Regurgitation and rumination (insufficiency of the cardia) 
should be treated chiefly by education and suggestion and by 
measures directed towards correcting the underlying neurosis. 
The patients should be told to chew their food thoroughly and 
to eat slowly. Inasmuch as the disease is frequently produced in 
friends or schoolmates of the patients by imitation, isolation of 
the patient in an institution, aside from facilitating the treat- 
ment of the patient himself, is often effective in preventing- 
the spread of the disease in persons closely associated with the 
sufferer. 

Gastric atony has already been discussed in a previous sec- 
tion (see index). The treatment of the neurotic variety dif- 
fers in no way from that produced by organic or mechanical 
causes. 



Neurotic secre- 
tory perver- 



SECRETORY NEUROSES. 

The secretory neuroses of the stomach that manifest them- 
selves as hypersecretion and hyperchlorhydria, as hypochlorhy- 
dria and achylia, have already been discussed in special sections,, 
so that it is needless to repeat here what has been said. If one 
is dealing with a purely neurotic form of secretory neurosis, 
then, in addition to the dietetic, mechanical and medicinal means- 
that have been recommended for the treatment of these condi- 
tions, recourse must be had to the use of the general hydro- 
therapeutic, and electrotherapeutic means and all the other meas- 
ures that are used in the treatment of neuropathic individuals. 
In the same sense organic lesions in and around the stomach or 
in remote organs that may by reflex irritation cause functional 
perversions of the gastric secretion, must be sought for and cor- 
rected, if possible. 



GASTRIC NEUROSES 411 

SENSORY NEUROSES. 

Gastric hyperesthesia may occur as an independent affection, Gastric hyper- 
but it is usually found attended by secretory perversions of the 
stomach. It is indicated by a variety of abnormal sensations 
about the stomach, as fullness, tension or burning, or by severe 
paroxysms of pain, i. e. gastralgia proper. Gastralgia occurs in Gastralgia 
many organic diseases of the stomach and also in affections of 
organs adjacent to the stomach as, for instance, in the presence 
of adhesions, aneurism of the abdominal aorta, aortic insuffi- 
ciency, (see page 19), in neuroses of the solar plexus, especially 
in sexual disorders, in cord diseases (gastric crises of locomotor 
ataxia) and in a variety of intoxications and infections, in con- 
stitutional diseases (poisoning with tobacco or lead, in malaria, 
Addison's disease, the uratic diathesis, chlorosis, tuberculosis, 
etc.). Finally, paroxysms of gastralgia may be a part phenom- 
enon of neurasthenia or hysteria. 

Manifestations of gastric hyperesthesia or attacks of gas- Causal treat- 
tralgia occurring when the stomach is empty are best relieved by men 
the ingestion of food. If hyperesthesia or gastralgia are not due 
to remediable causes, or if the latter are not discoverable or, 
again, if these symptoms, occurring in a neurotic subject, do not 
yield to the general treatment of the underlying neurosis, then 
certain measures for the symptomatic relief of gastric pain must 
be employed. 

One of the most useful measures is the application of heat Symptomatic 
to the epigastrium, either by means of hot poultices made of treatment 
oatmeal, linseed, or bread, and medicated with a few drops of Heat to epi- 
opium or belladonna tincture; by the use of a Leiter coil (see 8&S rmm 
index) through which hot water is flowing, ur by means of 
a so-called Winternitz compress applied as follows: A wet wintemitz 
linen cloth is applied over the epigastrium; over it is placed compress 
a Leiter coil through which flows hot water and over this again 
another wet sheet ; the whole is covered with a flannel. By the 
use of this Winternitz compress a prolonged heat effect and 
considerable counter-irritation is produced. The thermophore, 
as described on page 39, is also useful for the application of con- 
tinuous heat to the epigastrium. Electrization 

Electrization of the stomach too is of some value in the of stomach 
treatment of hyperesthesia and gastralgia. Either the intra- 
ventricular or extra-ventricular method may be employed. In 
the former case the anode should be inserted into the stomach 
through a stomach tube, in the latter case the anode should be 
applied to the epigastric region by means of a large plate elec- 
trode. The cathode is connected with a large sponge electrode 
applied either to the sternum or between the shoulder blades. 



412 



GASTRIC NEUROSES 



Gastric 
douches 



Morphine 

Chloroform 
Cocaine 

Bromoform 
Antineuralgics 



Nervous dys- 
pepsia 



Alternation of 
diet 



Starvation 
plan 



A weak galvanic current is applied for not longer than ten min- 
utes (see also page 390). 

Douching the stomach with chloroform water or with silver 
nitrate solution 1 :1000, or simply with hot physiological salt 
solution, is a very useful measure, especially in cases that do 
not yield to the simple application of heat to the epigastrium. 

For internal use a variety of remedies can be employed. 

Morphine in the dose of one-eighth to one-fourth grain, 
or codeine phosphate in the dose of half a grain, may occasion- 
ally have to be given hypodermically, or a suppository contain- 
ing extract of opium and belladonna (see page 409), may be 
used. A few drops of chloroform on ice, or ice cold chloroform 
water in teaspoonf ul doses, sometimes afford relief. Cocaine 
is a useful remedy administered by pouring twenty drops of a 
five per cent, solution of cocaine in a third of a glass of water 
and administering a teaspoonf ul of this solution every fifteen 
minutes. Bromoform in two or three drop doses on ice, or in 
a teaspoonful of ice water, or in a 1 :1000 solution, a teaspoonful 
every two or three hours, may also be used. Finally, antineu- 
ralgic remedies as antipyrin, phenacetin in five to fifteen grain 
doses (0.3 to 1 gm.), lactophenin or exalgin in eight to fifteen 
grain doses (0.5 to 1 gm.), or pyramidon (especially in tabetic 
crises) in the dose of fifteen to thirty grains (1 to 2 gm.) ad- 
ministered with water two or three times in one or two hour 
intervals, may be employed. 

In the treatment of "nervous dyspepsia" suggestion and the 
appropriate hydrotherapeutic and electrotherapeutic measures, 
massage or a Weir Mitchell fattening rest cure, as described 
above, are usually sufficient to bring about a cure. Any reflex 
disorders should be removed (see page 402). The patients should 
be protected from care, worry and excitement and any 'psychic 
or emotional shock. No fixed rules in regard to the diet can be 
formulated. Some patients do exceedingly well on a Weir 
Mitchell fattening cure, others on a starvation plan, some thrive 
on an exclusively vegetable diet, others on milk feeding, still 
others, on a mixed general diet. Very often a change from one 
diet to another acts beneficially for a time ; and it is generally a 
good plan, partially, it must be confessed, on account of the 
suggestive effect produced, to alternate with the diet, feeding the 
patient for a time on vegetables exclusively, letting him hunger 
for a week, and giving him rectal feeding for another period, 
then allowing a general diet for a time or a milk diet, or insti- 
tuting a Weir Mitchell cure. 

A starvation plan with rectal feeding should always be given 
a trial. Within certain limitations the caprices of the patient 



ACUTE INTESTINAL CATARRH 413 

should be considered and if a general diet is permitted, great 
care should be exercised to render the food palatable and tempt- 
ing to the patient. In no disease are the arbitrary methods of 
the doctrinaire more dangerous than in this disorder. Care 
should always be exercised not to administer any really indiges- 
tible foods that might produce genuine dyspepsia; for the lat- 
ter would produce a bad moral effect upon the patient who can- 
not distinguish between a real and a nervous dyspepsia. That 
every endeavor should be put forward in all these methods of 
feeding to maintain full nutrition, excepting possibly for short 
periods of time, need hardly be emphasized. 

Smoking is, as a rule, to be forbidden. Alcohol in the form Smoking 
of dilute whisky or brandy, Claret or Moselle as a table bever- Liquor 
age, may be used in moderate quantities. 

Rest after eating is also a useful measure for. reasons that Best after 
have been discussed above. Lavage and douching are 
rarely indicated in nervous dyspepsia and whatever good effects 
may be witnessed from the use of these measures must be attrib- 
uted largely to their suggestive influence. Medicines play a very 
subordinate role in the treatment of nervous dyspepsia. Stom- 
achics and hydrochloric acid given as discussed on page 359f, 
can do no harm. Any accompanying constipation or diarrhea 
should be combated chiefly by dietetic and mechanical means and 
bj^ medicines only in extreme cases. 



III. THE INTESTINE. 

ACUTE INTESTINAL CATARRH. 

Causal treat- 
Most cases of intestinal catarrh are due to irritation of the ment 

bowel wall by toxic or infectious agencies. The latter may be 

ingested with the food and irritate the bowel directly from 

within, or they may be borne to the intestinal wall through the 

blood. Causal treatment must attempt, therefore, above all 

things, to promptly rid the organism of these toxic bodies. In 

the case of the blood-borne toxins this is not always an easy 

task. In some instances, however, as in malarial toxemia where 

we possess specific antimalarial treatment (see page 546), this is Malarial di- 

possible. In catarrh of the bowel occurring in the course of arr kea 

other infections and intoxications and due to the circulation of xj rem i c di _ 

bacterial toxins or of metabolic poisons (e. g., uremic diarrhea) arrhea 

through the bowel wall with irritation of the bowel mucosa, very 

little can be done towards attacking the primary cause of the 

intestinal disorder. 

Acute intestinal catarrh due to the ingestion of toxic mate- 
rial is much more amenable to causal treatment. If the poison 



414 



ACUTE INTESTINAL CATARRH 



Eliminants 



Calomel 



Castor oil 



Bowel irriga- 
tion 



Mode of insert- 
ing? rectal tube 



is one that is foreign to normal food and if its character is 
known, the appropriate antidote should, self-evidently, 
be administered at once, and removal of the offending 
material promoted by lavage of the stomach and free evacuation 
of the bowel contents. 

In all forms of food poisoning, whether due to mechanical 
irritation of the bowel wall by coarse foods or compacted feces 
in chronic constipation, or to chemical irritation from poisons 
contained in spoiled foods or formed from the gastro-enteric 
contents by abnormal bacteria vegetating in the bowel, prompt 
emptying of the intestine and evacuation of the noxious agency 
is the first rule. 

The two principal eliminants that should be employed in 
these cases are calomel and castor oil. Drastic purgatives and 
salines should not be used in acute catarrh of the bowel, as they 
irritate the inflamed mucosa still more. 

Calomel is best given in one large dose of three to five grains 
(0.2 to 0.3 gm.). Smaller doses are more apt to irritate the 
bowel wall without exercising so pronounced a purgative effect. 
Castor oil should be given in the dose of half an ounce to an 
ounce (one to two teaspoonfuls to an infant or a little child) 
either in gelatin capsules or in a small glass of beer or in beef 
tea; or the oil may be mixed with peppermint water, or with 
milk flavored with peppermint oil and rapidly gulped down; 
or it may be poured into a wine glass and an equal quantity 
of sherry or port wine superimposed and the whole taken in 
one swallow. In order to mitigate the severe griping and colic 
that frequently follows the use of castor oil, a few drops of 
tincture of opium, or a drop of cinnamon oil, may to advantage 
be added to the dose. 

Removal of the offending material from the bowel should also 
always be promoted by irrigation of the large intestine. The 
rectal catheter used for colonic flushings should be about thirty 
to forty centimeters long and should have a lumen of about 
one centimeter. Before inserting it all the air should be driven 
out of the tube by filling it with water from the funnel or irri- 
gating bag it is connected with. The tube should always be well 
lubricated with oil or with vaseline and should be inserted gently 
and carefully with a slow rotary movement until fifteen to 
thirty centimeters have entered the bowel. If the tube catches 
it should not be pushed in forcibly, but slowly withdrawn a 
little and reinserted. The patient should be placed either on the 
left side with the right leg drawn up and the hips elevated by 
one or two pillows, or in the knee-chest position, or in the dor- 
sal position with raised hips. As soon as the tube is in place the 
irrigating fluid is allowed to flow in very slowly and under low 



ACUTE INTESTINAL CATARRH 415 

pressure, i. e., from a height not to exceed two feet. Fully ten 
to fifteen minutes should be consumed in injecting two liters; in 
this way retention of the irrigating fluid is made much easier 
and less pain and discomfort are produced. If the water stops 
flowing altogether, this may be due to the impaction of a fecal 
plug in the opening of the tube or to knuckling of the catheter; 
in either case the tube should be withdrawn a few inches. If 
the flow does not start again, then the catheter must be entirely 
withdrawn, cleansed and reinserted. 

For the purpose of colonic flushing, pure water, normal salt irrigating 
solution 6 to 8 to 1000, soapy water or water medicated with fluids 
a tablespoonful of glycerin to the quart, or with certain laxa- 
tive, disinfectant or astringent remedies (see page 420), may be 
used. In some cases in which there is much impaction of hard 
fecal material in the lower bowel, a preliminary injection of six 
to eight ounces of olive oil may be practised in order to pro- 
mote softening of the contents of the large intestine. 

After removal of the poisonous and irritating bowel con- R es t f the 
tents by calomel or castor oil and by rectal irrigation, the next bowel 
most important rule is to place the bowel wall at rest, to spare 
the intestinal mucosa in order to allow the undisturbed re-estab- 
lishment of normal conditions. 

In order to do this, the following dietetic rules should be ob- Diet 
.-served : During the first twenty-four hours complete absti- 
nence from food is the best plan, and this treatment can usually Abstinence 
he carried out without difficulty because the patients sponta- 
neously refuse to eat. The severe thirst that suffererers from Thirst 
acute intestinal catarrh usually experience during the first 
twenty-four hours can be relieved by small swallows of sterile wa- 
ter or tea, or b}^ allowing the patient to dissolve pieces of ice in 
the mouth. Chewing gum is also an efficient means to relieve the 
sensation of thirst. Inasmuch as sufficient liquid to satisfy the Water by- 
water requirements of the organism cannot and should not be rec um 
supplied in this way, irrigation of the colon with normal salt 
solution may aid in supplying this deficit. 

In very mild cases a little gruel or soup made of oatmeal, rice Gruels 
or barley flour, sago, arrow-root or tapioca and water, carefully 
strained and flavored with a little salt or a little meat extract, 
may be allowed on the first day, in tablespoonful doses. In all 
•cases this diet is permissible on the second day. In addition, Albumen water 
the patients may receive a little albumen water or egg-nog made 
of the whites alone ; a little Claret or brandy diluted with boiled 
water, or weak tea should constitute the chief beverages on the 
second day. 

Milk is well borne by some subjects and not at all by others. Milk 
It should never be given raw in cases of acute intestinal catarrh, 



416 



ACUTE INTESTINAL CATARRH 



Diet after the 
third day- 



Food to be 
avoided 



Drugs 



Intestinal anti- 
septics 



Calomel 

Dilute H CI 

Resorcin 

Menthol 

Creosote 

Salicylic acid 

Salol 

Beta-naphthol 

Benzo-naphthol 



Danger of met- 
allic anti- 
septics 



but only boiled or carefully sterilized, never cold and never too- 
hot, but only lukewarm in small quantities at a time and best 
with a tablespoonful of lime water or a teaspoonful or two of 
brandy to the tumblerful. If milk increases the diarrhea, then 
buttermilk or kumyss or kephyr, administered in tablespoon 
doses, may be tried. The nourishing character of these milk 
preparations renders them very useful provided they can be 
borne. 

On the third day it is permissible to add a little toast, zwie- 
back or crackers to the above dietary. In addition, meat broths 
with an egg, or some cocoa may be given. This simple, semi- 
liquid diet should be continued until the diarrheic discharges 
have stopped; then a little raw, scraped meat or broiled beef 
or mutton may be given, also squab or some white meat of 
chicken, meat jelly, gelatinous food, a little rice or tapioca, some 
vegetable purees and mashed potatoes. 

All fried foods, foods prepared with much fat, fresh fruit,, 
acid or spiced foods, very hot or very cold foods should be avoid- 
ed for some days after the diarrhea has stopped. 

Special medicines are rarely required in the treatment of 
acute intestinal catarrh. Certain of the group of intestinal 
antiseptics may ' be employed to hold the development of the 
bacterial flora in the intestine in check. The use of some of 
the intestinal antiseptics, sodium glycocholate, organic perox- 
ides and sulpho-carbolates has already been fully discussed in 
the Section on Bright 's Disease, page 207. Other intestinal an- 
tiseptics that can be used are calomel in very small doses, i. e. 7 
a twentieth to a tenth of a grain, two or three times a day. In this 
dose calomel does not irritate the bowel wall nor does it purge, 
but merely inhibits bacterial life. Dilute hydrochloric acid in 
five to ten drop doses may be given for a similar purpose. The 
following remedies may all be tried: Resorcin in five per cent, 
solution, three to five teaspoonfuls a day; menthol, two grains 
(0.12 gm.) two or three times a day; creasote, one to three drops 
(0.06 to 0.18 gm.) in brandy or wine several times a day or in 
olive oil, in gelatin capsules or in solution with some simple 
syrup; salicylic acid, five to thirty grains (0.3 to 2 gm.) in cap- 
sule or in solution ; salol, in the same dose ; naphthaline, one to 
five grains (0.06 to 0.3 gm.) • beta-naphthol, three to ten grains 
(0.2 to 0.6 gm.) ; benzo-naphthol, five to ten grains (0.3 to 0.6 
gm.). 

In acute intestinal catarrh particular care should be exer- 
cised to avoid the administration of intestinal antiseptics that 
are irritating to the bowel wall; thus most of the metallic salts 
with antiseptic properties, with the exception of calomel given 
as above, should be eschewed. A very useful preparation is 



ACUTE INTESTINAL CATARRH 417 

ichthoform, a combination of formaldehyde and ichthyol, which ichthoform 
splits off formaldehyde in the intestine. It should be given in 
two to three grain doses, twice or three times a day. 

Many of the above intestinal antiseptics can to advantage be Administration 
given in keratinized pills or glutoid (Sahli) capsules, i. e., cap- Siig 6 ™* 1 ^ 1 * 6 ^ 
sules, made of gelatin hardened with formaldehyde or, also, capsules 
in pills coated with salol; in this way they pass through the 
stomach unchanged and exercise their full effect in the bowel. 

Astringent remedies are not often indicated in acute catarrh Astringents 
of the bowel. They should never be used during the first two 
or three days. If the diarrhea persists for many days unin- 
fluenced by other measures, then some of the astringent group of 
medicines may have to be employed. They will be discussed in 
full in the Section on Chronic Intestinal Catarrh. 

Narcotics are generally superfluous. If there is much pain Narcotics 
and if the diarrhea persists, despite the complete evaluation of 
the irritating bowel contents by calomel or castor oil and by in- 
testinal irrigation, then opium or morphine may have to be re- 
sorted to. Opiates stimulate the nerves that inhibit intestinal 
peristalsis, i. e., check the latter. They also render the sensory 
nerve endings in the bowel less sensitive to irritation by bowel 
poisons and thereby also aid in arresting peristalsis. The best 
mode of administering opiates is either in suppository with bella- 
donna (of each extract % grain), or in the dose of fifteen 
to twenty drops of the tincture of opium as an enema in starch 
water (two teaspoonfuls of starch flour in eight ounces of 
water). If there is much gastric or rectal irritation, so that 
the administration of opium by mouth or rectum is disagreeable 
then morphine in one-sixteenth or one-eighth grain doses may be 
given hypodermically. 

The constipation following the use of opiates, as well as the Constipation 

following' opi- 
constipation that generally follows the diarrhea in acute intes- ates or di- 

tinal catarrh, calls for no special treatment. It may be allowed arrhea 

to persist for several days after the diarrhea is checked and 

should then, if necessary, be relieved by enemas and by the 

proper diet (see Section on Constipation). 

Heat applied to the abdomen in the form of hot water bags, Heat 
poultices, hot compresses or dry, hot cloths is always grateful 
to those afflicted with acute intestinal catarrh and materially 
aids in reducing the colicky pain. If there is much flatulency, 
turpentine stupes (cloths wrung out of hot water medicated with stu P es 
two or three drops of oil of turpentine) or enemata medicated 
with two or three drops of turpentine or with carminative rem- 
edies are useful (see also Section on Meteorism) . 

If there is fever rest in bed should be enforced. Cases of Fever 



418 



CHRONIC INTESTINAL CATARRH 



Analeptics 



acute intestinal catarrh that manifestly follow exposure to cold, 
should be given a hot bath, wrapped in blankets and allowed to 
sweat. Drop doses of the tincture of aconite repeated four or 
five times, at hour intervals, or a ten grain Dover's powder, 
given in the beginning, often aid in shortening the attack. That 
the other measures described for the treatment of acute intes- 
tinal catarrh should be employed in addition, is self-evident. 

In cases that go into collapse analeptic remedies like cam- 
phor, ether or ammonia (see page 32) should be administered. 
Hot alcoholic drinks should be taken, hot water bags or bottles 
put to the feet and legs, the extremities rubbed with rough 
towels, and the patient wrapped in woolen blankets with an ice 
bag to the head. 



General indi- 
dications 



Diet 



General char- 
acter of diet 



Forbidden 
foods 



CHRONIC INTESTINAL CATARRH. 

In no case of chronic intestinal catarrh is it possible by any 
known means to directly influence the diseased condition of the 
intestinal mucosa. All one can do is to avoid further irritation 
of the inflamed area by the selection of the proper food and by 
the administration of drugs that prevent the formation of irri- 
tating products in the bowel and their stagnation in intimate 
contact with the catarrhal lining membrane of the intestine. 
At the same time general hygienic means may be employed in- 
tended to improve the general health and nutrition of the pa- 
tient and thus enable him to put forward the maximum effort 
towards restoration of tissue integrity. 

The diet, above all, in chronic intestinal catarrh, as in any 
other chronic disorder, should be nutritious enough to satisfy the 
daily caloric requirements of the individual. The ingestion 
of sufficient calories is often a difficult task owing to the ex- 
istence of diarrhea with loss of valuable pabulum in the stools, 
and also on account of the presence of chronic catarrhal changes 
in the intestinal mucosa which interfere with the proper intes- 
tinal digestion and hence render only part of the ingested food 
available for the nutrition of the patient. 

Generally speaking the diet, aside from being nutritious, 
should also be non-irritating to the bowel wall, i. e., it should con- 
tain no coarse or indigestible particles, no spices, condiments, no 
very acid, very sweet or very fat foods of any kind. Fruits 
and salads are forbidden. 

In selecting a general dietary from permitted articles, the 
individual likes and dislikes of the patient must be considered. 
In so prolonged a disorder as chronic intestinal catarrh it is 
worse than useless to force the patients to eat articles of food 



CHRONIC INTESTINAL CATARRH 419 

that they thoroughly dislike. On the other hand to be too arbi- 
trary in absolutely forbidding small quantities of articles of 
food that theoretically might be harmful, but that the patients 
crave, is also bad practice. The stimulation of the appetite 
above all is an important element in aiding digestion and in 
maintaining the nutrition of the patient. 

The main index, however, that teaches whether or not an Analysis of 

article is well borne and properly digested is an analysis of the stools as index 

J for the dietary 

stools. A study of the feces after various "test meals" is of 

equal importance here as the analysis of the stomach contents in 
stomach disorders. Whenever an article, that, on theoretical 
grounds, is indicated and permissible, persistently reappears in 
the stools in a semi-digested or undigested form, then its fur- 
ther administration becomes worse than useless; for not only 
does it not contribute to the patient's support, but it positively 
aggravates the catarrhal condition of the intestinal mucosa by 
its action as a mechanical or chemical irritant throughout the 
length of the intestinal canal. 

The following articles, with the above reservations, are the useful and per- 
most useful in chronic intestinal catarrh: All meats of tender missible foods 
varieties, especially white meats, fish and poultry, always finely Meats 
divided and freed from skin and tendon; meat jellies (see page 
536), gelatinous foods, meat broths; eggs should be given only Eggs 
soft boiled, scrambled and prepared with very little fat. Gruels Gruels 
made with water or milk and tapioca, sago, arrow-root, rice, 
barley flour, etc., are useful. Milk is usually well borne in Milk 
chronic intestinal catarrh even when administered in large quan- 
tities, provided it is altogether fresh, otherwise it may become 
troublesome. It is always safer to administer it boiled or care- 
fully sterilized than raw. The digestibility of milk, as repeat- 
edly stated, may be increased by the addition of lime water or 
of a little brandy. Kephyr, kumyss and buttermilk are also Buttermilk 
allowed. The lactic acid contained in these beverages acts, to Kephyr 
some extent, as an intestinal antiseptic and may be useful on Kumyss 
these grounds. Cereals and bread stuffs, noodles, macaroni and Cereals and 
other dishes made of flour are permissible, provided they are bread stuffs 
not prepared with too much fat. Of breads, sour and coarse 
kinds should never be given, but chiefly dried bread, toast, crack- 
ers, zwieback. The fat demand may be supplied by fresh butter 
and cream, and vegetable oils; meat fats, like lard, suet and 
bacon are not so well borne. 

Of beverages, boiled water, sterile milk, a little dilute Claret Beverages 
or Moselle wine or whisky and water, mineral waters that have 
been shaken in order to cause the evaporation of carbonic acid 



420 



CHRONIC INTESTINAL CATARRH 



Diet in consti- 
pation 



Diet in di- 
arrhea 



Small meals 



Drugs 



Tannic acid 



Tannigen 
Tannalbin 



Catechu 
Rhatany 
Colombo 
Kino 



Bismuth prep- 
arations 



gas, tea and cocoa are all allowable. Beer, champagne, strong 
alcoholic liquors and coffee are to be denied. 

In cases of chronic intestinal catarrh accompanied by very 
obstinate constipation, a little more of cereals and fats, of fresh 
vegetables, even of fruits, may have to be given. In cases, on 
the other hand, that suffer from diarrhea more meat and milk 
and less of the above articles should be administered. 

Small meals at frequent intervals are always better than 
large meals. The patients should be instructed to eat very slowly 
and to thoroughly masticate their food. If at all possible they 
should be instructed to lie down or to rest quietly for from half 
an hour to an hour after the main midday and evening meals. 

For the purpose of inhibiting abnormal fermentative pro- 
cesses in the bowel a variety of medicines are used ; chief among 
these are tannic acid preparations, especially in that large group 
of cases of chronic intestinal catarrh that suffer from persistent 
diarrhea. The members of the tannic acid group are credited 
with "astringent" properties. As a matter of fact they aid 
chiefly by stopping putrefaction of bowel contents. The best tan- 
nic acid preparations in chronic intestinal catarrh are tannigen 
and tannalbin ; for neither of these drugs is attacked by the gas- 
tric juice, so that the tannin they contain really exercises its full 
effect upon the bowel contents. Tannic acid, itself, and prepara- 
tions of catechu, rhatany, Colombo, kino, etc., that all contain 
some tannic acid, may all be used in the diarrhea of chronic in- 
testinal catarrh (usually in combination with opium) to check 
fermentation, but they are not without effect on the stomach,, 
and, besides, a large part of the tannin is absorbed in the stomach 
and hence does not become available for use in the bowel. Tan- 
nalbin, however, an albumin compound of tannin, containing 
about five per cent, of the latter and rendered resistent to peptic 
digestion by heating to 120° C, enters the bowel unchanged and 
is there split up by the alkaline intestinal juices. Tannigen 
(diacetyl tannic acid) possesses similar properties. Each of these 
remedies should be given in ten to thirty grain (0.6 to 2 gm.) 
doses several times a day, in powder form. 

Next in importance to tannic acid preparations in the treat- 
ment of diarrhea due to chronic intestinal catarrh are a variety 
of bismuth preparations. The exact mode of action of bismuth 
in these cases is not altogether understood. It is probable that 
it acts mechanically by forming a coating over the inflamed 
mucosa and thereby protects it against irritating bowel con- 
+ ents. Bismuth, in order to be effective, should be given in large 
quantities, either as the subnitrate or as the subsalicj^late in 
doses of fifteen to thirty grains (1 to 2 gm.) in powder, three 



CHRONIC INTESTINAL. CATARRH 421 

or four times a day. Both these bismuth preparations can, to 
advantage, be given together with a little extract of opium. Two 
other good preparations of bismuth are dermatol given in the Dermatol 
dose of one and a half to three grains ((0.1 to 0.2 gm.) and 
xeroform* in the dose of fifteen to sixty grains (1 to 4 gm.). Both Xeroform 
of these preparations are split up in the bowel into bismuth and 
tannic acid, in the case of dermatol; or an aromatic antiseptic 
radical in the case of xeroform, so that they combine the mechan- 
ical action of bismuth with the antiseptic action of the tannin 
and phenyl derivative they incorporate. 

The administration of other metallic salts, lead acetate, zinc Metallic salts 
suphate, alum, or silver nitrate is not so common nowadays as 
it used to be. These remedies are all quite irritating to the 
bowel wall and the stomach, and as it is most important to pre- 
vent injury to the gastric wall in chronic catarrh of the intes- 
tine, the use of all these drugs must be considered somewhat pre- 
carious. The advantages derived from their antiseptic action are 
more than overbalanced by their irritating effect. The least 
harmful of all this group of medicines is silver nitrate, which 
is promptly converted into silver chloride and silver proteid Silver nitrate 
compounds in the stomach, both substances that possess only 
slight irritating powers, but very powerful germicidal proper- 
ties. Silver nitrate should be given in dessertspoonful doses 
of a 1 :100 solution, three or four times a day. 

In addition to the administration of antiseptics and astrin- 
gents by mouth, free evacuation of the bowel should be promoted, 
especially in all cases of chronic intestinal catarrh accompanied 
by constipation ; an occasional dose of castor oil in combination Castor oil 
with an enema is, therefore, of benefit in these cases; or a va- 
riety of mineral waters may be employed. 

Just how mineral waters act in chronic intestinal catarrh is Mineral waters 
not understood. Empirically it is universally recognized that 
they favorably influence not only symptoms like constipation or 
diarrhea, but that they materially aid in restoring normal con- 
ditions about the bowel mucosa. That this good effect is not due 
alone to life at a resort where these waters are taken, or to rest 
and the proper regime that is carried out in these watering 
places, is shown by the benefits accruing to sufferers from 
chronic intestinal catarrh from the use of these waters at home. 
Alkaline and saline waters are the best, chief among them the 
waters of Carlsbad, Vichy, Marienbad. They should be taken Alkaline-saline 
hot, a tumblerful on rising, another one in the middle of the (Carlsbad, _ 
forenoon and a third in the middle of the after- * n bad) waters 

♦To the same group of aromatic bismuth compounds belong eudoxin, 
orphol, dermol, bismuth sulpho-carbolate, -cresolate and -plienolate. 



422 



CHRONIC INTESTINAL CATARRH 



Sulpho-saline 
waters 



Colonic flush- 
ings 



Opium in the 
diarrhea of 
chronic intes- 
tinal catarrh 



Hydrotherapy 



noon. The water should always be taken slowly in small 
swallows. Some patients cannot tolerate these waters on an 
empty stomach and they fare better if they take their first 
glass after breakfast. Waters of this type are most effective in 
cases of chronic intestinal catarrh associated with diarrhea. 

If there is much constipation, or if constipation and diarrhea 
alternate, then the sulpho-saline waters, or waters containing 
Glauber salts,- are best. These should be taken cold and the 
quantity administered should be gauged by the action of the 
bowels. The proper quantity is enough to produce free daily 
evacuations. These waters, too, are best given after a meal and 
not on an empty stomach. In order to be effective these min- 
eral water "cures" should be kept up for long periods of time, 
i. e., their use should be continued at home and not only at the 
watering places for a few weeks once or twice a year. 

Colonic flushings and rectal irrigation are useful adjuvants 
to the treatment. In performing irrigation of the rectum and 
colon, either simple warm water or normal salt solution may be 
used. As a rule water of body temperature is the best. If, how- 
ever, there is very much pain or irritation about the lower bowel, 
then hot irrigations of 105° to 110° F. are more grateful to the 
patient. Of antiseptics and astringents that may be employed to 
medicate the irrigating water, tannin, 5:1000; silver nitrate 
0.5:1000; salicylic acid, 1:1000; boric acid, 5:100; and creo- 
line, 1 :1000, may be mentioned. Injections of 500 to 1000 cc. of 
olive oil, warm, are also very useful. 

Opium preparations should be given with care in the diarrhea 
of chronic intestinal catarrh, and only as a last resort in order 
to secure symptomatic relief from pain and to stop persistent 
diarrhea that will not yield to any of the other measures spoken 
of above. The danger of opium treatment lies in this, that the 
drug by checking intestinal peristalsis favors stagnation of fer- 
menting bowel contents, and hence may increase the bowel irri- 
tation. In view of the slightly irritating effect that opium occa- 
sionally exercises upon the gastric mucosa the drug is best given 
in the form of suppositories or hypodermically, either alone or 
in combination with belladonna (see page 409), or in combination 
with some of the above mentioned astringent and antiseptic 
remedies. 

Hydrotherapeutic measures are of subordinate importance 
in the treatment of chronic intestinal catarrh. Priessnitz com- 
presses applied to the abdomen are, however, useful and generally 
agreeable to the patient. If there is much diarrhea with violent 
peristalsis and considerable irritation of the bowel and pain, a 
Winternitz compress (see page 411), or hot turpentine stupes are 



INTESTINAL STENOSIS AND OCCLUSION 



423 



very useful. Iu obstinate constipation on the other hand sitz 
baths, cold douches, Scottish douches, are often of great benefit. 
The latter measures with exact indications for their employ- 
ment and the technique of applying them will be found described 
in full in the Sections on Diarrhea and Constipation. 

A patient suffering from chronic intestinal catarrh, espe- 
cially with acute exacerbations, with persistent diarrhea, pain 
and tenesmus, should remain in bed until the attacks of diar- 
rhea are checked or greatly reduced. Cases of chronic intestinal 
catarrh with chronic constipation, on the other hand, should 
indulge in a mild amount of exercise. No fixed rules in regard 
to rest and exercise can be formulated but the peculiarities of 
each individual case must be studied and rules made accordingly. 

The clothing and footwear should be carefully selected to 
protect the patient from catching cold. In winter woolen under- 
wear and stockings and thick shoes should always be worn. An 
abdominal binder made of flannel or wool should be worn all 
the year round. During the warm weather a hardening process 
may be begun and carried on into the winter, as described in the 
Section on Rhinitis. 



Rest and ex- 
ercise 



Clothing and 
footwear 



INTESTINAL STENOSIS AND OCCLUSION 



Surgical vs. 
internal treat- 
ment 



Most cases of occlusion of the bowel, immaterial whether 
they develop independently and suddenly or whether they de- 
velop less acutely on the basis of chronic stenosis of the bowel 
that gradually progresses to complete obliteration of the bowel 
lumen, are amenable to surgical treatment alone. Not infre- 
quently, however, a case will be encountered in which a restora- 
tion to normal conditions is produced by internal treatment. 
Such cases, in the very nature of things, are rare and constitute 
probably not one-third of all intestinal occlusions that are seen. 
This happy outcome manifestly can only occur under certain 
definite anatomic conditions to be specified below, whereas, in 
the majority of cases, the obturation of the bowel is of such a 
mechanical character that it can only be relieved by radical, 
mechanical, i. e., surgical, means. 

It will be seen, therefore, that the indications for internal or indications for 
for surgical intervention are dependent altogether upon the na- 
ture of the occlusion ; and, as it is in most cases impossible to 
make an altogether positive diagnosis in this direction, internal 
treatment should only be employed tentatively and never for 
longer than forty-eight hours after the onset of the first symp- 
toms of bowel occlusion. If at the end of this time patency of 
the bowel lumen is not re-established, recourse should be had 



surgical or 
medical treat- 
ment 



424 



INTESTINAL STENOSIS AND OCCLUSION 



Fecal ob- 
struction 



Gall stone 
occlusion 



Occlusion from 
pressure from 
without 



Intussusception 



to surgery. The different internal measures, to be presently 
described, should, therefore, be tried quickly and in rapid suc- 
cession in the hope that one or the other of them may lead to the 
goal and obviate the necessity of a laparotomy. 

The following forms of bowel occlusion occasionally yield to 
internal treatment : 

Above all, fecal obstruction, i. e., occlusion of the bowel by 
a plug of fecal matter occurring either as the result of obstinate 
constipation and coprostasis, in an otherwise patent canal, or 
occurring on the basis of a chronic narrowing of the lumen of 
the bowel by cicatricial stenosis or neoplastic growth from with- 
in, or by compression of the bowel from without by some en- 
larged or dislocated organ, by peritoneal adhesions or thicken- 
ing of the bowel wall. In the latter category of cases removal 
of the fecal obturator which may be very small or may consist 
merely of some coarse or indigested food particle, is, however, 
more difficult than in simple fecal stasis. Occlusion of the 
bowel lumen by a large gall stone or some other foreign body is 
also amenable to internal treatment in a certain proportion of 
cases. Here, too, the presence or absence of chronic stenosis 
determines to a large extent the facility with which the obturator 
may be expected to pass on and out under appropriate medical 
treatment. The obstruction is (self -evidently) removed much 
more rapidly if the bowel lumen is normal throughout its course 
than if it is constricted or stenosed in some portion. Here the 
previous history of the case, the existence of stenosis symptoms 
prior to the occurrence of the occlusion, must, to a large degree, 
determine the treatment. 

Occlusion of the bowel by pressure from without, especially 
by compression of the bowel by large movable organs or tumors 
adjacent to the bowel, may yield to bandaging and manipula- 
tion and to placing the patient in certain positions in which the 
large abdominal mass that produces the compression is held away 
from the bowel. In this group such non-surgical treatment is, 
however, purely palliative and in most instances merely prelim- 
inary to an operation. 

Intussusception of the bowel also occasionally yields to in- 
ternal treatment (opium, atropine, lavage, irrigation, — see be- 
low) ; most cases, however, do not. An attempt to relieve the ob- 
struction by non-surgical means should, therefore, always be 
made in these cases, but one should never persist in this treat- 
ment for longer than forty-eight hours at the utmost. Upon the 
appearance of collapse symptoms, or evidence of an impaired 
heart's action (see below), recourse should at once be had to 
surgical mean* 



INTESTINAL STENOSIS AND OCCLUSION 425 

The same rules, provided the diagnosis can be made at all, volvulus kinks 
apply to volvulus and slight kinks of the bowel, although here 
the probability of restoring bowel patency by internal treatment 
is even smaller than in the case of intussusception. 

All the other forms of bowel occlusion, namely, firm strangu- strangulation 
lations, either internal or external, severe kinking or knotting Knotting 
of the bowel, double axial rotation, are surgical altogether from Axial rotation 
their onset and to waste time with internal measures in the • 
treatment of these forms of ileus is bad practice. 

Even in the first named group of cases that may be said to indications for 
occupy a position on the borderland between surgery and medi- instituting pre- 
•cine, a variety of elements about the general condition of the cal treatment 
patient must determine the advisibility of trying non-surgical 
means first, or of having recourse at once to operative interfer- 
•ence. 

The considerations that should govern us in instituting 
preliminary internal treatment are the following: The method 
of treating any cases of internal occlusion by medical means, 
i. e., of adopting an expectant plan, is justified by the fact 
that about one-third of the cases recover without an operation. 
Of this group by far the greatest number, it is true, are due 
to fecal obstruction. Some clinicians claim, furthermore, that 
to wait is always good practice, because repeated examinations 
of the patient will enable the physician to make a better diagno- 
sis, to localize the seat of the obstruction and hence formulate 
more clean cut indications for surgical intervention. As a mat- 
ter of fact I have never found this to be the case; for if the 
Junior or swelling in the abdomen cannot be found on first ex- 
amination, it is usually still more difficult to find it later in 
the course of the disease, on account of the meteorism and the 
muscular rigidity that generally develop within twenty-four 
hours and renders the palpation of the abdomen much more 
•difficult than in the beginning, even if an anesthetic is given. 

As against the expectant plan surgeons advance the just Arguments 

argument based on conservative statistics that the mortality a & ains t the ex- 
.... . . pectant plan 

from an operation in this disorder increases in proportion to 

the length of time that is permitted to elapse between the onset 
of occlusion symptoms and the operation. They argue, further- 
more, with some justice, that internal treatment, especially the 
use of opium and the reduction of the intra-abdominal pressure 
by lavage or colonic irrigation, produces a sense of euthanasia, 
relieves the patient's distress and hence engenders a false sens* 7 
of security in the patient, the friends and the physician; fur 
thermore, raises false hopes that are apt to be shattered; and 
above all, favors loss of valuable time during which the intra- 



426 



INTESTINAL STENOSIS AND OCCLUSION 



Critique of 
above argu- 
ments 



The heart's 
action 



abdominal conditions are really being aggravated and the 
chances of recovery from surgical intervention are being re- 
duced. 

All these arguments, pro and con, would, it appears, speak 
directly for surgery in every case of bowel obstruction. Un- 
fortunately, however, operative interference, even in the most 
skillful hands, is always dangerous in this disease, probably less 
safe than laparotomy performed for almost any other acute 
intra-abdominal disorder. This is due to the peculiar condi- 
tions created by intestinal occlusion, the necessity in most cases 
of exploring large areas of the abdomen and of submitting many 
feet of the intestine to manual examination; the existence of 
meteorism with bowel distention, possibly paralysis of the bowel 
wall and, above all, in many cases, ulceration and great fria- 
bility of the intestine. In most cases, in fact, the operation will 
have to partake of the character of an exploratory laparotomy 
and often the surgeon will have to content himself with estab- 
lishing an artificial anus or performing a simple enterotomy, re- 
serving the radical operation for a second occasion, provided the 
patient should be so fortunate as to survive the shock of the 
first emergency inroad. Cases in which the exact location of 
the occlusion and its precise character are known before the oper- 
ation, or in which the occluded area is quickly found after 
laparotomy, are unfortunately relatively rare and even in these 
the success of the operation is of necessity doubtful, as every- 
thing depends upon the mechanical conditions discovered and 
the possibility of relieving them promptly by surgery. 

Surgery is, therefore, by no means the panacea for occlusion 
of the bowel that one might imagine it to be. There are cases 
in which it is our only means of succor, but there are also many 
cases in which surgery, as well as medicine, is helpless, and there 
are still other cases, constituting, as stated above, about one- 
third, in which the patients get well without an operation. A 
conservative expectant plan with the adoption of all the non- 
surgical means we know of is, therefore, justified in the large 
class of cases delineated above, provided, of course, the patient 
is carefully watched during this time and everything is held in 
readiness for the operation should the necessity for it suddenly 
arise. 

So long as the heart's action is good, i. e., while the arterial 
tension is normal or slightly elevated, the pulse full, strong and 
of moderate rapidity ; so long as no symptoms of acute strangu- 
lation or collapse (cold sweats, cyanosis, cold extremities, etc.) 
appear, it is generally safe to rapidly try all the non-surgical 
means. As soon as the heart begins to fail, the pulse becomes 



INTESTINAL STENOSIS AND OCCLUSION 427 

small, rapid and thready, the blood pressure low; if collapse 
occurs or signs of peritonitis or perforation develop, then no 
time should be lost in placing the patient on the operating table. 

The existence of collapse symptoms, appearing even one or Collapse 
two days after the onset of occlusion, or collapse occurring from 
the initial shock of the occlusion, cannot be considered a contra- 
indication to surgical intervention; for without the operation 
these patients will surely die and with the aid of surgery they 
have at least a chance of recovery. Peritonitis or perforation do 
not prohibit a laparotomy; for in the light of modern surgical 
experience an occasional case of localized, even of mildly dif- 
fused peritonitis, unless too horribly septic, recovers after lapa- 
rotomy. 

The internist has a number of means at his disposal for over- The means of 
coming intestinal obstruction, chief among them lavage of the the mtermst 
stomach, irrigation of the lower bowel, inflation of the rectum 
and colon with water or carbonic acid gas, the use of laxatives 
in some cases, of opium in others, massage, counter-irritation by 
means of heat or cold. The employment of mercury that was The use of 
formerly so popular in ileus is being discarded nowadays as ]^te CUry 
useless and occasionally harmful. 

For the application of all these measures distinct indications 
and contra-indications exist in the different forms of intestinal 
occlusion that may now be discussed. 

Lavage of the stomach and removal of the stomach contents, Lavage 
which is generally abundant and frequently contains fecal ma- 
terial, acts favorably in three ways, viz : 

First, lavage reduces the intra-abdominal pressure and hence 
greatly relieves the most distressing symptoms, especially vom- 
iting and flatulency; at the same time it decreases the violence 
of peristaltic movements and favors the straightening of kinked 
or twisted bowel loops. 

Second, lavage causes removal of a mass of toxic material 
accumulating in the stomach that may do serious harm by pro- 
ducing general symptoms of toxemia, especially about the heart 
and nervous system, if allowed to remain behind or if only in- 
completely evacuated by spontaneous vomiting. 

Third, lavage in many cases, materially aids in the evacuation 
of the bowel contents above the constricted area ; for as soon 
as the stomach is thoroughly emptied by lavage, regurgitation 
of bowel contents into the stomach occurs, so that within a few 
hours the stomach will generally be found full again. In some 
cases during the performance of lavage new masses of fecal mat- 
ter will suddenly appear in the stomach even after the wash 



428 



INTESTINAL STENOSIS AND OCCLUSION 



Time of per- 
forming lavage 



Contra-indica- 

tion 



Bowel irriga- 
tion 



Contra-indica- 
tions 



waters were already clear, showing how rapidly bowel contents 
in this condition can regurgitate into the stomach. 

It is obvious, therefore, that in cases of bowel occlusion 
lavage of the stomach should be performed repeatedly and at 
short intervals. It is always good treatment to wash out the 
stomach at two or three hour intervals until nothing more of 
fecal material can be pumped out. It is unnecessary to wait for 
fecal vomiting before performing lavage, as removal of the 
stomach contents, even if it is not contaminated with bowel eon- 
tents, is good practice on account of the reduction of the intra- 
abdominal pressure and the removal of toxic stagnating mate- 
rial that is thereby brought about. Moreover, the stomach may 
contain abundant fecal material and still no fecal vomiting occur. 

The one contra-indication to gastric lavage is severe collapse. 

In cases that are distinctly surgical m character and in which 
an operation has been decided upon, gastric lavage is also of 
signal benefit ; for it is manifestly easier to manipulate the bowel 
after laparotomy if the stomach is small and empty than if it is 
large, heavy and distended, and occupies a large space in the 
abdomen; besides the danger of vomiting under an anesthetic 
and the occurrence of pneumonia from aspiration of foul vom- 
ited material is greatly reduced if lavage of the stomach is per- 
formed as a preliminary to the operation. 

Bowel irrigation is always of value in intestinal occlusion. 
In ileus, due to fecal obturation, it is, of course, the sovereign 
remedy. It is generally of use in impaction of a gall stone or of 
some other foreign body. In occlusion of the colon it is self- 
evidently of value, immaterial whether the occlusion is due to 
the impaction of a fecal plug in a chronically stenosed, con- 
stricted area of the colon, or whether the ileus is due to invagin- 
ation with the abdominal mesentery. In most cases irriga- 
tion of the lower bowel acts mechanically by softening and re- 
moving the fecal plug or loosening the impacted foreign body. 
In invagination the use of an eight to ten per cent, salt solution 
(see below) by producing anti-peristaltic waves may even act 
directly curatively ; for • as soon as the anti-peristaltic waves 
reach the invaginated area the obstruction may disappear. In 
kinks or twists of the sigmoid flexure irrigation helps both by 
removing heavy, dragging fecal masses and by producing stretch- 
ing and straightening of the affected bowel section ; and, even in 
ileus in the small intestine, the peristaltic and anti-peristaltic 
waves that are stimulated may be of signal benefit in promoting 
restoration of bowel patency. 

There are distinct contra-indications to the use of rectal or 
colonic irrigation, namely, ulceration or great friability of the 



INTESTINAL STENOSIS AND OCCLUSION 429 

bowel wall that may be suspected and feared in a variety of dis- 
orders that produce intestinal occlusion. It is also clear that 
rectal irrigation should not be repeated if, in a given case, the 
first enema does not promptly return, or if the patient is alto- 
gether unable to retain the injected fluid. In some cases irriga- 
tion of the bowel becomes impossible on account of the presence 
of large, hard masses of impacted feces in the rectum or lower 
bowel. Here an attempt should always be made to soften the 
latter by the injection of small quantities of oil or, if neces- 
sary, to remove them mechanically with a blunt spoon or some 
other instrument. 

The technique of rectal irrigations and of colonic flushings Solutions to be 
has already been described (see page 422). The best irrigation em P lo y ed 
fluid in ileus is a ten per cent, solution of sodium chloride 
in water. Salt solutions of this concentration produce anti-per- 
istaltic waves so that the water is often carried up as far as the 
lower portion of the ileum. One other great advantage of these 
strong salt enemata is that only small quantities, i. e., from 300 strong salt 
to 400 cc. need be injected in order to produce the same effect, enemata 
or even a greater one, than would ordinarily be produced by 
the introduction of several litres of any other injection fluid. 
By using these strong salt enemata, therefore, the increase of 
the intra-abdominal tension and excessive stretching or disten- 
tion of the bowel is avoided. The addition of a few ounces of 
infusion of senna, or of some other laxative infusion to the salt 
clysma, can do no harm, but is, as a rule, superfluous. 

The use of cold enemata or of ice water given for the pur- Cold enemata 
pose of stimulating peristalsis is always dangerous, especially in 
cases threatened with collapse or actually in collapse. This meas- 
ure is unnecessarily severe and in view of the diagnostic 
uncertainties obtaining in each case of bowel occlusion, and the 
inability to predict in advance whether or not stimulation of 
peristalsis is desirable (see below), it is sometimes decidedly pre- 
carious. Small clysmata of warm water or of physiological 
salt solution are much better. They should be injected very slowly 
in order to avoid over-distention of the bowel. Rectal irrigation 
should be performed at intervals of three or four hours until the 
bowel passage is cleared or the time for operation has arrived. 

Injections of one-half to one litre of lukewarm olive oil can Oil injections 
always be given with safety as a preliminary measure. They are 
very useful to soften and dissolve hardened fecal masses or to 
loosen a fecal plug and to render the way open for the passage 
of after-coming bowel movements. 

Inflation of the lower bowel with air or carbonic acid gas Air inflation 
possesses no particular advantages, so far as its mechanical effect 



430 



INTESTINAL STENOSIS AND OCCLUSION 



Technique of 
inflation 



Opium 



Objections to 
opium 



Bationale of 
opium 



is concerned, over the injections of water, oil or salt solutions; 
as the latter, aside from distending the bowel, aid in cleaning out 
the intestine, they are by all means preferable. Following a 
series of fluid injections an air or carbonic acid gas inflation may, 
however, be practised to advantage, especially as this method of 
distending and stretching the lower bowel is often better borne 
and less distressing to the patient than distention with the 
heavier fluid irrigations. Inflation, too, is particularly useful 
in invagination and in kinks or partial rotation of the sigmoid 
flexure. The same contra-indications to the use of air and gas in- 
flation exist as in the case of water injections, namely, friabil- 
ity of the bowel wall and ulceration, provided the existence of 
these conditions can be determined, or is even strongly suspected. 

To perform inflation of the rectum and colon with air a rec- 
tal tube is joined by a T tube with an air bulb. The free limb 
of the T tube is connected with a piece of rubber tubing held 
shut with a clamp. When it is desired to allow the escape of 
air from the rectum, this clamp is opened. To inflate the rectum 
with carbonic acid gas the rectal tube may be connected with an 
ordinary siphon and carbonated water injected into the bowel, 
or a watery solution of bicarbonate of soda is injected first and 
a solution of tartaric acid immediately afterwards. Of the 
former, twenty grammes, of the latter, fifteen grammes are com- 
monly used. 

A violent controversy has been going on for many years 
between physicians and surgeons in regard to the administra- 
tion of opium in occlusion of the bowel. Internists generally 
advise its use in all cases as a routine measure in the beginning 
of the disease. Surgeons, on the other hand, condemn its em- 
ployment, claiming as stated above, that it produces merely a 
sense of euphoria, lulls the medical attendant into a sense of 
false security, permits aggravation of the bowel condition and 
favors waste of valuable time before the operation is finally per- 
formed. 

Inasmuch, however, as opium certainly relieves the suffering 
of the patients and in some cases, by reducing peristaltic move- 
ments, directly aids in restoring normal conditions, its use during 
the first twenty-four hours is indicated and can be advised. If, 
at the end of this time, the bowel lumen is not open, the sur- 
geon in any doubtful case comes into his right anyhow, and so 
much at least has been gained by the administration of opium 
that the patients remained relatively comfortable during the 
time that internal treatment was administered. That severe 
collapse symptoms from reflex irritation emanating from the 
bowel and peritoneum are often prevented and that the section 



INTESTINAL STENOSIS AND OCCLUSION 431 

of bowel immediately above the obstruction is not so unduly 
stretched and injured by continuous packing of bowel contents 
into this area, when opium has been given to allay the violent 
peristaltic movements of the bowel, must be conceded. Even in 
those cases, finally, that are surgical from their onset, opium 
can do no harm. On the contrary it usually does good by pre- 
venting collapse, by quieting the general sensibilities and ner- 
vousness of the patient and also by reducing the violence of per- 
istalsis. The surgeon's plea against opium, provided the drug 
is given only during the first twenty-four or forty-eight hours, 
cannot, therefore, be considered valid. 

To summarize, opium is permissible in all cases of intestinal 
occlusion. In cases that are clearly surgical from their onset 
(and to know this is one of the most difficult and uncertain tasks 
of diagnosis) the drug can do no harm when given as a prelim- 
inary to the operation. In cases in which the diagnosis is alto- 
gether doubtful opium should be given for twenty-four to forty- 
eight hours, first, for the purpose of relieving the patient's 
anxiety and restlessness, and to allay the vomiting and mitigate 
the terrific pain; second, for counteracting the sudden, early 
collapse from reflex irritation emanating from the sensory nerves 
of the intestinal peritoneum ; third, for reducing the over- violent 
intestinal peristalsis and hence preventing to some extent, dam- 
aging paralysis, ulceration or perforation in the bowel area sit- 
uated immediately above the obstruction. In certain forms of 
intestinal occlusion, finally, chiefly invagination, volvulus or 
slight degrees of kinking or twisting of the bowel, the arrest of 
peristalsis that is brought about by opium, combined with other 
measures (lavage, irrigation, etc.), may even aid in restoring 
normal conditions. 

In order to be effective large doses of the drug should be Dose and ad- 
given early in the disease. As the absorptive powers of the 
stomach are usually greatly reduced or inhibited in occlusion 
of the bowel and as opium, moreover, is a distinct irritant to 
the gastric mucosa and may precipitate vomiting, it is best ad- 
ministered not by mouth but in suppository or hypodermically. 
The exact dosage depends somewhat on the reaction of the in- 
dividual to the opiate. The proper dose in any case is enough 
to produce the desired effect. It is best given in amounts of 
half a grain (0.03 gm.) of the extract, every one or two hours, 
in suppository or in the form of a watery solution of the ex- 
tract of the strength of 1 :10. Of the latter, an amount corre- 
sponding to about a third of a grain (0.02 gm.) should be in- 
jected every two hours until the desired effect is produced; or 
morphine should be injected in the dose of an eighth to a fourth 



432 



INTESTINAL STENOSIS AND OCCLUSION 



Opium in 
collapse 



Atropine 



of a grain, every two or three hours, until the patient is clearly 
under the influence of the drug. 

If the rule is observed not to rely upon opium for longer 
than forty-eight hours in cases in which the bowel lumen is not 
reopened by that time, no harm can be done and the. most se- 
rious objection against its use, namely, production of a false 
sense of security, is rendered invalid. After forty-eight hours 
have elapsed the administration of opium is unnecessary unless 
the drug is given for purposes of euthanasia in cases in which 
an operation cannot be performed. Above all things, it is im- 
portant to remember that the relative comfort of the patient 
when under the influence of opium should never constitute a 
contra-indication to an operation. The only criterion that should 
guide the internist in advising an operation is whether or not 
the bowel is open at the expiration of forty-eight hours; for^ 
while some cases have been known to live for many days with 
complete occlusion of the bowel, this event is exceptional. 

Whereas opium may be considered an efficient remedy to 
prevent the occurrence of collapse early in occlusion of the 
bowel, it should be given with great care in collapse occurring 
later, i. e., after the expiration of twenty-four or forty-eight 
hours, an accident that is especially liable to happen in cases that 
have not had the benefit of opium treatment from the beginning. 
To give large doses of opium suddenly in these instances is a 
precarious matter; for the weak heart, the peripheral cyanosis^ 
the cold extremities, the rapid, thready pulse constitute direct 
contra-indications to the use of the drug. If, in such patients,, 
it becomes necessary on account of the great pain to give opium 
or morphine, then these drugs should, by all means, be adminis- 
tered in combination with some analeptic like ether, camphor or 
ammonia to support the heart. 

Atropine should be given with the same reservations as 
opium. No time should be wasted with atropine treatment in 
clearly operative cases, nor should its use ever be continued for 
more than two days. Any patient with occlusion of the bowel 
who is treated with atropine should be carefully watched and 
if resolution does not promptly occur, recourse should be had 
to an operation. It is known empirically that atropine is occa- 
sionally highly effective in causing reopening of the bowel lu- 
men. All the favorable cases, however, were presumably due to 
fecal obstruction or occlusion of the bowel by a large gall stone 
or other foreign body, or cases of "dynamic" ileus. In view of 
the difficulty of diagnosing the precise character of the occlu- 
sion, it is clear that too much reliance should never be placed 
upon atropine, especially as its mode of action in these cases is. 



INTESTINAL STENOSIS AND OCCLUSION 433 

very obscure. It is doubtful how the remedy acts, whether it 
reduces secretion in the bowel above the obstruction and hence 
prevents distention of this intestinal area with fluid, or whether 
it aids by contracting the blood vessels in the occluded area and 
hence reduces the thickness of the bowel wall. Atropine should 
be given, hypodermically, in large doses of a sixtieth to a thir- 
tieth of a grain (0.001 to 0.002 gm.), three or four times in the 
course of thirty-six to forty-eight hours. If the bowel passage 
is not opened after the third injection, then it is useless to con- 
tinue the exhibition of atropine any further. 

It will be seen, therefore, that the use of atropine in ileus in- 
variably partakes of the character of a therapeutic experiment 
that, in rare cases, produces brilliant results, but unfortunately, 
in the majority, produces no results whatever. As no harm can 
ever accrue to the patient from the use of atropine, especially if 
lavage, irrigation, etc., are performed at the same time, and pro- 
vided valuable time is not wasted thereby in clearly surgical 
cases, the administration of three or four doses of the drug can 
be recommended in most cases. This applies even to cases of ileus 
that develop on the basis of a chronically stenosed bowel; for 
here the removal of the fecal plug, or the foreign body, which 
may have produced the complete occlusion has occasionally been 
facilitated by atropine. In cases, finally, that are clearly due 
to fecal obstruction or to impaction of a gall stone in an other- 
wise normal intestine it is especially useful. 

Laxatives are distinctly contra-indicated in all forms of acute Laxatives 
intestinal obstruction, with the possible exception of fecal occlu- 
sion of the bowel. If the latter diagnosis can be positively made, 
and this will be an exceptionally rare event, laxatives may be 
safely given. Even in this group of cases, however, they should 
be given early in the disease as otherwise paralysis of the bowel 
wall above the fecal plug may have supervened. In this case 
removal of the fecal ping by the use of laxatives would not 
materially relieve the situation ; for the mass of after-coming 
bowel contents would be packed forcibly into the paralyzed 
area which, being unable to propel this mass onward, would 
in its turn become obstructed by a new and more bulky fecal 
plug. Besides, in fecal obstruction of somewhat longer stand- 
ing, especially when it develops upon the basis of a chronic 
progressive stenosis of the bowel, there is always danger of 
ulceration and increased friability of the intestinal wall above 
the obstructed area, so that in these cases the administration of 
laxatives favors rupture or perforation. Several cases are on 
record in which this accident occurred after the administration 
of laxatives. 



434 INTESTINAL STENOSIS AND OCCLUSION 

In cases of ileus, finally, in which the character of the occlu- 
sion is doubtful laxatives should, by all means, be withheld; 
for if the bowel occlusion is not due to fecal obstruction they 
may do serious harm even if given early. 

In nearly all cases of ileus laxatives increase the distress 
of the patient, especially the vomiting and the pain. Often- 
times, in fact, fecal vomiting only occurs after the administra- 
tion of purgative drugs. On account of the increased pain and 
peristalsis that may be produced by these remedies, collapse, too, 
may be precipitated by their use. Finally, purgatives may do 
decided harm in ileus due to knuckling of the bowel, strangu- 
lation, axial rotation or intussusception. This can sometimes be 
positively determined, in cases that present favorable conditions 
for examination, by palpation of the abdomen ; for upon the ad- 
ministration of laxatives the abdominal tumor will be felt to 
grow harder and larger. In occlusion due to a foreign body 
or to a gall stone impaction, purgatives do very little good; for 
the bowel wall is already putting forward its maximum effort 
to propel the obstacle onward, and to over-stimulate peristaltic 
movements that are already abnormally exaggerated can only 
do harm. 

It will be seen, therefore, that laxatives are preferably alto- 
gether avoided in any form of ileus unless the case is one of very 
recent fecal obstruction occurring in an individual whose bowel 
movements, up to the time the ileus occurred, were normal in 
calibre. Late in fecal obstruction, or in any other form of sud- 
den occlusion of the bowel, laxatives are best avoided. In view 
of the great difficulty of making a positive diagnosis of fecal 
obstruction in any case the administration of laxatives in general 
is to be condemned. 

Massage of the bowel performed by an expert masseur, pre- 
ferably under an anesthetic, sometimes aids, when used in com- 
bination with other measures, in relieving occlusion of the bowel 
due to a fecal plug or an impacted gall stone or foreign body. 
Massage may be performed either by directly kneading and 
pushing the obturation onward, or by stimulating the bowel wall, 
around and immediately above the occluded area, to increased 
contractions. Here, again, this method of treatment is dan- 
gerous in cases of fecal occlusion or foreign body obturation that 
are not quite recent, on account of possibly causing rupture of 
the friable intestine or of producing perforation of a stercoral 
ulcer that may have formed in the area of coprostasis. 

In all the other forms of intestinal occlusion massage must 
be considered altogether dangerous, especially on account of 
the friability of the intestinal wall, and the danger of ulceration 



INTESTINAL STENOSIS AND OCCLUSION 435 

or gangrene about the occluded area. In fecal obstruction of the 
colon, however, massage of the large intestine, preceded by an 
oil injection to soften the fecal plug, is of considerable value, 
but, even in this variety of cases, one can get along very well 
without massage. Consequently this method of treatment, which 
was formerly very popular, must be considered to have an ex- 
ceedingly limited field of application. 

Electric treatment is, in most cases, a waste of time. The Electricity 
only condition in which it might do some good would be in 
bowel paralysis following the removal of the obturator. This 
sequel of ileus may be treated by applying two electrodes to 
the abdominal surfaces and passing a strong faradic current 
through them, or by applying one pole to the abdomen and in- 
serting the other one in the rectum and using a galvanic cur- 
rent. Either form of current should be used in the same man- 
ner and same strength as described in Stomach Diseases, on 
page 390. 

Hot or cold applications to the abdomen in the form of hot Hot and cold 
water bags, stupes, compresses, a thermophore or a Leiter coil applications 
charged with hot or cold water are useful as counter-irritants, 
chiefly to aid in controlling the pain. If peritonitic symptoms 
appear, cold is more useful than heat, otherwise the sensations 
of the sufferer alone must be considered and heat or cold ap- 
plied according to the likes and dislikes and the general reaction 
of the patient. 

In cases of very extreme meteorism in which surgical relief Meteorism 
cannot be promptly obtained, or in which the patient or rela- 
tives refuse an operation, puncture of the intestine with a fine 
needle trocar not larger in calibre than the needle of a hypo- 
dermic syringe, may be performed in order to promote the escape 
of gases. In this way the intra-abdominal pressure may be 
materially reduced and some symptomatic relief obtained. In Puncture of 
addition, the reduction of the pressure occasionally aids in re- the howel 
lieving certain forms of intestinal obstruction. Here the same 
effect is produced as by the relief of abdominal pressure by 
stomach lavage (see page 427). Paracentesis of the bowel must, 
however, always be considered a very precarious procedure and 
one that should never be resorted to in any case in which a 
laparotomy can be performed, or in which there is any possible 
way to obtain relief of the meteorism by other means. The chief 
danger from puncture of the bowel is evidently the development 
of peritonitis, especially in cases in which the bowel is paralyzed 
or gangrenous. Under these conditions the puncture opening 
may not close promptly or completely and bowel contents ooze 
into the peritoneal cavity. Inasmuch as over-distention of the 



436 



INTESTINAL STENOSIS AND OCCLUSION 



Diet 



Thirst 



Hypodermo- 
clysis 



Rectal feeding 



bowel from excessive meteorism frequently leads to paralysis or 
even gangrene, it will be seen how dangerous this operation is. In 
fact, the interference with the normal blood supply in the bowel, 
that commonly results from the over-stretching of the bowel 
wall, renders it possible for gangrene to develop secondarily 
about the trocar opening, so that perforation or rupture of the 
bowel and peritonitis may follow some time after the puncture 
has been performed. The operation, moreover, is not always 
easy to perform and it may occasionally be necessary to insert 
the needle several times before a loop of bowel is actually punc- 
tured; or the bowel may be punctured but no gas escape, so 
that a second or a third insertion of the needle may become 
necessary. Under these conditions, the dangers resulting from 
the puncture are, of course, still more increased. 

Very little need be said in regard to the diet in cases of 
acute intestinal occlusion. Complete abstinence from solid or 
liquid food is absolutely necessary. The introduction of any 
food by mouth can only increase the accumulation of material be- 
hind the obstacle. In ileus, the administration of food or 
drink is a useless procedure inasmuch as the power of the stom- 
ach or intestine to absorb any of the gastric or intestinal 
contents is practically inhibited. Moreover, vomiting, which 
may be aggravated by the introduction of food, would promptly 
expel everything that might be introduced into the stomach. 
There is rarely any difficulty in maintaing total abstinence from 
food, as the patients themselves never manifest a desire to eat 
anything. 

Most of them, however, suffer from excessive thirst. This 
symptom is usually materially allayed by the use of opium, as 
described above. If the thirst is very distressing, it may be 
somewhat relieved by allowing the patient to suck a little ice, 
or to allow ice pills moistened with a few drops of brandy to 
dissolve in the mouth. They should always be instructed not to 
swallow the water. Washing out the mouth at frequent intervals 
with plain water or soda solution is usually very grateful to 
the sufferers. 

The administration of water by hypodermoclysis in the form 
of normal salt solution, or in the same form by rectal irrigation, 
is a useful means of supplying to some extent the water demands 
of the organism. 

Rectal feeding, however, is rarely indicated, especially if 
an operation is performed within forty-eight hours after the 
onset of the trouble in all cases that do not yield to other means 
by that time. 



INTESTINAL ULCER 437 

In chronic stenosis of the bowel in which the time for opera- Diet in chronic 
tion has not yet arrived, or in which the conditions producing stenosis 
the stenosis are unalterable, or in which the patient refuses an 
operation, the diet should, as a prophylactic means, be arranged 
in such a way as to prevent a sudden occlusion of the stenosed 
area. In order to fulfill this purpose a diet that leaves the 
smallest possible residue in the bowel and that contains no coarse 
particles that might form a plug in the stenotic area, is advis- 
able. The food, therefore, should consist largely of milk, eggs, 
broths, strained gruels, vegetable purees, butter, cream, scraped 
or hashed meats, carefully freed from skin and tendons. Raw 
fruit and vegetables containing seeds, stems, pips, kernels, skins, 
etc., cereals containing husks, pips, seeds, stems, skins, coarse 
breads and similar foods should be absolutely forbidden. The 
patient should be instructed to most carefully masticate his food 
and to eat small meals at a time. 

Any tendency to constipation should be overcome by giving constipation 
fruit sauces and abundant fat with the diet and by instructing 
the patient to drink olive oil once or twice a day. At the same 
time the lower bowel should be kept thoroughly cleaned out by 
means of enemata (see page 450), and, with great care, mild 
vegetable laxatives like cascara, rhubarb, senna, etc., or gently- 
acting laxative waters, or an occasional dose of castor oil may 
be administered. In cases, however, in which the stenosis has 
advanced to such a point that the peristaltic action of the intes- 
tine is greatly increased, as manifested by the appearance of 
visible and palpable peristaltic waves on the abdomen, laxatives 
of any kind are, to say the least, superfluous. For, in these 
cases, the bowel wall is manifestly already putting forward its 
maximum effort to overcome the obstruction. Here, in fact, 
much more can be gained from the administration of opium, for 
reasons that have been discussed in full above, than from the 
administration of laxatives. 

In sudden intestinal occlusion occurring on the basis of a 
chronic stenosis of the bowel, the same rules of treatment obtain 
as in any other form of acute ileus, only that here the indica- 
tions for surgical intervention are more exact and positive, be- 
cause generally abundant time has been given to determine the 
nature of the lesion and its precise location in the abdomen. 



INTESTINAL ULCER. 

The treatment of ulcer of the bowel is largely limited to the 
symptomatic relief of the diarrhea, the pain and the hemor- 
rhages. 



438 



INTESTINAL ULCER 



Causal treat- 
ment 



Rest in bed 



Diet 



Hot and cold 
applications 



Internal rem- 
edies 



Bismuth 



The causal treatment of ulceration of the bowel occurring in 
the course of different infectious diseases, as tuberculosis, ty- 
phoid, dysentery, erysipelas, variola, sepsis, etc., is synonymous 
with the treatment of the underlying disorder. The same ap- 
plies to the causal treatment of intestinal ulcers occurring in the 
course of leukemia, gout, the hemorrhagic diathesis, or in uremia. 
Syphilitic ulcers of the bowel are self -evidently amenable to anti- 
luetic treatment. Stercoral ulcers occurring as the result of 
chronic constipation or in stenosis of the bowel, if they are at 
all discovered before perforation occurs, should be treated by 
correction of the underlying constipation, or mechanically, i. e., 
by surgical correction of the stenosis of the bowel lumen. The 
radical removal of an ulcerous area by excision may be included 
under the possible methods of causal treatment. 

A patient, with an intestinal ulcer producing much diarrhea, 
or causing much pain and showing a tendency to hemorrhage, 
should remain in bed. The diet, broadly speaking, should be ar- 
ranged according to the same principles that obtain in chronic 
catarrh with diarrhea, i. e., it should be free from mechanical, 
chemical or thermical irritants, should be easily digestible and, 
at the same time, sufficiently nutritious to maintain the physical 
equilibrium of the patient. The ideal, therefore, is a nutritious 
liquid or semi-liquid diet consisting largely of milk, broths, milk 
dishes, strained gruels, etc., given in small quantities and at 
frequent intervals. 

Heat or cold applied to the abdomen in most cases materially 
aid in relieving the severe distress of the patient and in reducing 
violent peristaltic movements of the bowel; they, therefore, act 
curatively, in a sense, by allowing the bowel to remain at rest 
and by checking the diarrhea. If there is evidence of periton- 
ize irritation, cold applications to the painful area, provided it 
can be definitely localized, are the best, otherwise, heat, either 
dry or moist, is more pleasant to the patient and probably more 
efficacious. The patient should be instructed to keep the ice bag 
or the hot water bag, or the Leiter coil, or the compress contin- 
uously in place. 

Very little can be expected from internal remedies given for 
the purpose of healing an intestinal ulcer. The most popular 
preparations and the ones that are almost universally employed 
for this purpose are bismuth salts and tannin derivatives. If bis- 
muth is given, it should be administered in large quanties, prefer- 
ably in pills coated with salol ; for the latter resist the acid gas- 
tric juice and are not dissolved until they reach the alkaline 
medium of the intestine. It is questionable whether even large 
doses of bismuth can really form a coating over one or multiple 



INTESTINAL ULCER 439 

ulcers when distributed throughout the length of the small intes- 
tine. Bismuth may be given in the form of the subnitrate or the 
subgallate, or as dermatol in doses of fifteen to twenty grains 
(1 to 1.3 gm.), several times a day. 

Together with the bismuth a quarter or an eighth grain of 
opium can, to advantage, be administered ; for both the bismuth Opium 
and the opium possess hemostatic and anti-diarrheic properties 
and the latter, moreover, acts as an anodyne in painful ulcers. 
If opium is to be administered alone, it is better given in suppos- 
itory or clysma, or hypodermically, than by mouth, especially if 
larger quantities are to be administered. 

The best tannin preparations are tannalbin or tannigen (see Tann albin 
page 420), given either alone or with opium. The antiseptic anm & ei1 
properties of the tannin preparations combined with the anti- 
diarrheic and anodyne properties of opium make this a useful 
combination. 

Ulcers of the colon and rectum are amenable to local treat- Ulcers of 
ment. Here astringent and disinfectant irrigations may be em- rectum^ 
ployed. The safest disinfectant solutions are thymol, 1:100; 
salicylic acid or boric acid, 1 :500. Bichloride of mercury injec- 
tions or solutions of carbolic acid should never be employed in Astringents- 

i A - * n -, t , . , „ and disinfect^ 

ulceration ot the lower bowel, as there is always danger from ants 

this practice of producing general carbolic acid or mercurial 
poisoning. 

The most useful astringent solutions are silver nitrate, 
1 :100 ; or tannic acid in the same strength. Silver nitrate injec- 
tions or instillations frequently produce violent tenesmus. If 
these painful sensations persist for some time, or become unbear- 
able to the sufferer, then an injection of a salt solution will cause 
precipitation of the silver nitrate as silver chloride and stop the 
irritation. 

In case of intestinal hemorrhage, complete rest in bed and intestinal 
total abstinence from food should be insisted upon. Even after ner *orrhage 
the hemorrhage has stopped the diet should be liquid, exclusively, 
for several days or longer, i. e., until even chemical traces of 
blood have disappeared from the stools. The application of the 
ice bag to the abdomen is useless unless there is evidence of peri- 
tonitic irritation. The best remedy is opium given in supposi- 
tory or by mouth; it acts chiefly by arresting peristalsis and Opium 
hence placing the bowel at rest and favoring clotting and arrest 
of the hemorrhage. Ergot, given as the fluid extract in the dose Erg-ot 
of one to two drachms (4 to 8 cc), or as the dry extract in the 
dose of three to fifteen grains (0.2 to 1 gm.), by mouth, or as the 
Injectio Ergotina Hypodermica, three to ten drops, is, in my ex- 
perience, ri very doubtful value. Much better is hydrastis, Hydrastis 



440 



INTESTINAL ULCER 



Hamamelis 



Adrenalin 
chloride 

Calcium 
chloride 



Gelatin 

Bismuth 
Lead acetate 
Perchloride of 
iron 



Hemorrhages 
from colon or 
rectum 



Collapse and 
secondary hem- 
orrhage 



given as the fluid extract in doses of fifteen to sixty minims 
(1 to 4 cc), or as hydrastinine hydrochlorate, in doses of one- 
half to two grains (0.03 to 0.1 gm.), or as stypticine, in the dose 
of one-third to one-half grain (0.2 to 0.3) several times a day. 
Hamamelis, in the form of the fluid extract, in thirty minim 
(2 cc.) doses, repeated several times, is also a useful remedy. 
Very good results are often obtained from the use of adrenalin 
chloride, given in ten to fifteen drop doses of a 1 :1000 solution, 
several times at two or three hour intervals. Calcium chloride, 
in thirty grain doses (2 gm.) in watery solution, repeated sev- 
eral times, is also a method of treatment that is worthy of a trial. 
The latter remedy, of course, is given with the object merely of 
promoting coagulation. 

Gelatin solutions are also occasionally of use ; they should be 
administered as described in the Section on Ilemoptysis (page 
311). Bismuth and lead acetate and, above all, the perchloride 
of iron, three preparations that are very popular, are, in my 
experience, utterly devoid of value in arresting intestinal hem- 
orrhages. It is possible that the perchloride may be effective 
indirectly in large hemorrhages by causing the formation of a 
clot that acts as a tampon in the intestine. 

In hemorrhages occurring from ulcers of the colon or the 
rectum, irrigations with hot water are usually effective. Ice 
water injections are, as a rule, dangerous because they produce 
active peristalsis, which prevents clotting of blood and may lead 
to further hemorrhage. In very extreme cases, however, that 
resist all other treatment, ice water applied directly to the bleed- 
ing spot, provided it can be seen through the rectoscope or sig- 
moidoscope, may be tried as an emergency measure. The addi- 
tion of tannin, silver nitrate or alum to the hot water can do 
no harm ; better still are calcium chloride solutions, employed in 
the strength of 4:1000, for the latter salt in many cases 
aids in the local coagulation of the blood. Adrenalin solu- 
tions; solutions of the fluid extract of hamamelis; or a solution 
of" gelatin 10 :200, all administered in small quantities by rec- 
tum, are also often efficacious in arresting hemorrhage of the 
large intestine. 

The treatment of collapse symptoms occurring upon the 
onset or during the course of an intestinal hemorrhage, and the 
treatment of the secondary anemia that generally follows severe 
intestinal bleeding, has already been discussed in full in different 
sections of this book (see index). 



MEMBRANOUS ENTERITIS AND MUCOUS COLIC 441 



MEMBRANOUS ENTERITIS AND MUCOUS COLIC. 

The excretion of large quantities of mucus may accompany Definition 
any form of intestinal catarrh; it may also occur without enter- 
itis. Inasmuch as most cases of intestinal catarrh run their 
course without the expulsion of abundant mucus, one must 
postulate, in that variety in which mucous stools occur, the exist- 
ence of some specific element that determines the excretion of 
mucus. The exact character of this element is uncertain, but, in 
all probability it is a general neuropathic disposition that upon 
the incidence of certain determining factors like intestinal 
catarrh in enteritis membranacea, or chronic constipation in sim- 
ple mucous colitis (colica mucosa), leads to over activit}' of the 
secretory glands of the bowel. 

As a matter of fact, a nervous disposition and general neu- Neurotic ele- 
rotic manifestations will be found in nearly all cases suffering 
from either of the two diseases under discussion. Causal treat- 
ment in any case must, therefore, attack the underlying neuras- Causal treat- 
ment 
thenia or hysteria. In cases suffering from true enteritis, the 

intestinal catarrh must be treated, whereas in cases of mucous 
colitis, it is, of course, useless to treat a hypothetical catarrhal 
condition that does not really exist. 

As a prophylactic measure and as an important symptomatic 
treatment during the attacks, the evacuation of the mucus must 
be accelerated by artificial means; for in this way the attacks 
of colic are mitigated and abbreviated, or altogether aborted. 

The treatment of the underlying neurasthenia or hysteria Treatment of 
must be carried out according to the principles that have been 
•described at length in the Section on Gastric Neuroses. A rest 
cure with isolation, or a Weir Mitchell treatment; various 
hydrotherapeutic or electrotherapeutic measures; the removal 
of reflex irritation emanating from any organ of the body; 
-change of scene ; a pause in the daily routine ; respite from worry 
and mental overwork; avoidance of all psychic or emotional 
shocks ; in fact, all the psychic and physical means that are often 
so effective in re-establishing nervous equilibrium, must be em- 
ployed. The results from this treatment, the exact arrangement 
of which must needs vary according to the peculiarities of each 
individual case, the surroundings, the state of life of the patient, 
are generally very satisfactory, although, as a rule, not per- 
manent. 

The most effective means of producing evacuation of the To produce 

mucus is by irrigation of the bowel with warm water or with a evac "^ atlon °* 

the mucus 
normal salt solution containing from 6 to 8 grammes of sodium 



442 



MEMBRANOUS ENTERITIS AND MUCOUS COLIC 



Oil injections 



Combined oil 
and water in- 
jections 



The pain 
Opium 



Hot applica- 
tions 



Hot bath 
Laxatives 



chloride to the litre, or sodium bicarbonate solution containing- 
five parts to the litre. 

Better than water irrigations are injections of warm olive oil r 
especially during the attack; fully 500 cc. should be injected in 
the manner described on page 451. In cases with much pain,, 
five to ten drops of the tincture of opium may be added to the 
latter injection. The oil should always be injected slowly, ten to 
fifteen minutes being consumed in carrying out the treatment. 
The oil probably acts by dissolving the fecal masses clinging to 
the bowel and, in this way, aids in loosening the mucus; if it 
remains in the bowel long enough (and several days usually 
elapse before all the oil is evacuated) it is decomposed into oleic 
acid wh?ch stimulates peristalsis. Consequently oil injections 
constitute a very effective means to prevent stagnation of bowel 
contents in the colon and rectum. For the purpose of combating 
the chronic constipation, smaller quantities of oil, about 50 to 
100 cc. may be injected, daily, for a time, between the attacks, 
and in a sense as a prophylactic measure. 

Oil given in this way can to advantage be combined with a 
water irrigation in such manner that a hundred cc. of oil 
are emulsified by beating with the yolk of an egg, and this 
emulsion mixed with half a glass of water and injected by means 
of a small syringe high into the colon through a rectal catheter; 
an hour later the bowel is irrigated with a litre of lukewarm 
water. The best time for performing this treatment is after 
breakfast. 

The pain during the attack can be controlled by the addition 
of opium to the oil injection or, if necessary, by the administra- 
tion of small quantities of opium by mouth in the form of five 
drops of the tincture or as an eighth of a grain of the extract 
with a two hundredth grain of atropine. Opium, belladonna or 
atropine given thus are also the best remedies for the relief of 
chronic spastic constipation (see page 446) ; and inasmuch as 
the constipation in mucous colitis, as in most other neurotic 
disorders, is generally of the spastic variety, it will be seen 
that opium is a very useful remedy in this disease. It acts pre- 
sumably by deadening the irritability of the sensory nerves of 
the bowel and hence preventing the reflex spasticity of the intes- 
tinal muscularis. 

During the atack the pain can also be controlled to some 
extent by the application, externally, of hot cloths or turpentine 
stupes, hot poultices or a Leiter coil charged with hot water. 
Immersion of the patient in a warm full bath or a sitz bath is- 
also an exceedingly useful measure to reduce the severity of the 
pain and to abort the attacks. Laxative remedies are very rarely 



MEMBRANOUS ENTERITIS AND MUCOUS COLIC 443 

indicated in this disease. In the spastic type of constipation they 
do very little good and in the atonic type (see page 452) they 
are generally superfluous; for constipation of the latter variety 
can usually be corrected by dietetic and mechanical means alone. 
An occasional dose of castor oil or of calomel, or here and there 
one of the mild vegetable purgatives like cascara, rhubarb or 
senna, may become necessary in order to promote the evacuation 
of large accumulations of feces. All of these elements of the 
treatment, as well as the advisability of "educating" the bowel 
by insisting on an attempt at stool at a certain time of the day, 
suppressing the stool during others (a method of treatment that 
better than anything else aids in restoring the normal autom- 
atism of defecation) will be found described in the Section on 
Constipation. 

The diet, in cases of mucous colitis, should contain an abund- Diet 
ance of coarse, indigestible particles, i. e., plenty of fresh fruit 
and fresh vegetables, coarse bread and cereals containing cellu- Coarse, bulky 
lose, in other words, foods containing husks, pips, seeds, stems, foods 
skins, kernels, etc. The addition of two or three tablespoonfuls 
of bran to one of the breakfast foods is a very practical means 
of fulfilling this postulate. 

In addition plenty of fat in the form of cream, butter, olive p a t s 
oil on salad dressing, or in mayonnaise, bacon, sardines, meat fat, 
should be given; or the patient may be ordered to take two or 
three tablespoonfuls of pure olive oil once or twice a day. 

Occasionally the sudden transition from a bland mixed diet Sudden change 
to a diet containing abundant cellulose and indigestible particles of diet 
and much fat, aids materially in preventing attacks of mucous 
colitis and even in curing the disease. A diet, such as the one 
described, is of necessity bulky and fatty, at the same time flurry 
and aerated on account of the formation of C0 2 and CH 4 from 
the fermentation of the fruit acids and the cellulose that are 
ingested. That meats, eggs and all other foods that leave a 
small residue, should be correspondingly reduced and only given 
in such quantities as are necessary to adequately nourish the 
patient and supply his demands for albumen, need hardly be 
emphasized. 

In cases suffering from entero- and gastro-ptosis, the wearing Abdominal 
of an abdominal binder or bandages to support the abdominal bmders 
walls, or a fattening cure may materially aid. 



444 



CHRONIC CONSTIPATION 



Physiological 
constipation 



Alimentary- 
constipation 



Constipating 
effect of meat, 
eggs, milk 



Laxative effect 
of fruits and 
vegetables 



CHRONIC CONSTIPATION. 

There are several types of constipation and each requires 
special treatment. Before undertaking to manage a case of 
constipation a variety of factors must, therefore, be determined 
and, on the basis of this preliminary study, the plan of treat- 
ment arranged. 

In the first place it is important to recognize that many peo- 
ple evacuate the bowel contents only once in two or three days, or 
even at longer intervals, throughout their life time with no 
discomfort or any detriment from this habit. This condition of 
constipation must, therefore, be considered physiologic and if 
no morbid cause can be discovered and no untoward symptoms 
make their appearance, that are attributable to the infrequent 
bowel evacuations, then this form of constipation is negligible 
and no special treatment is called for. It must be remembered 
that the peculiar mechanism that at regular intervals, in 
most people once in twenty-four hours, propels the contents 
of the colon and sigmoid into the ampulla of the rectum and 
thereby produces the peculiar sensation that leads to the act of 
defecation (in pathological cases, tenesmus) is altogether auto- 
matic and that this automatism may very w^ell vary in different 
subjects. Here habit, or what may be called "education," plays 
an important role; or there may be a congenital element that 
determines less frequent relief of the automatic mechanism that 
in most people occurs once a day. 

There is a second form of constipation that is, in a sense, 
also physiologic and that may be called alimentary constipation. 
Here daily evacuation of the bowels occurs, but the stools are 
small and very solid. This form is readily corrected by the 
administration of the proper diet containing abundant vegetable, 
fat and carbohydrate material and relatively little albuminous 
food. 

For meat, eggs, and milk, the chief representatives of the 
albuminous foods, are so thoroughly disassimilated in the 
stomach and the bowel that they leave a very small residue; 
moreover, they incorporate only a small proportion of indigesti- 
ble material and hence produce a small amount of feces ; finally, 
very few chemical bodies are contained in albuminous food and 
few are formed in the bowel from their disassimilation that can 
stimulate peristalsis. 

Vegetables and fruits, on the other hand, contain abundant 
indigestible cellulose material, skins, pips, seeds, husks, stems, 
etc., that leave a large and bulky residue and also mechanically 



CHRONIC CONSTIPATION 445 

irritate the bowel waJl to increased peristaltic action. In addi- 
tion, the organic acids and other salts that most fruits and 
vegetables contain, furnish material lor the development of C0 2 
in the bowel by the action of intestinal bacteria and this gas, 
aside from rendering the stools fluffy, accelerates the peristaltic 
movements of the bowel. 

The sugar, finally, contained in fruits and vegetables, or Laxative action 
formed from the starches contained in these products, is also starches' 3 ^ 
promptly decomposed into C0 2 and CH 4 , and these gases again 
render the stools voluminous and stimulate peristalsis. Sugar, 
moreover, on account of its hygroscopic properties, prevents the 
absorption of water from the bowel and hence aids in main- 
taining a liquid or pultaceous character of the stools. 

Fats act as laxatives both by lubricating the wall of the Laxative action 
intestine, hence rendering the propulsion of the bowel contents ats 
easier and, by favoring the formation of various acid bodies, 
soaps and glycerin, in the bowel, all of which possess laxative 
and peristalsis stimulating properties. 

A diet, therefore, like that described above, usually produces 
copious stools in alimentary constipation and no further treat- 
ment of this condition is, as a rule, required. 

There are, however, some forms of constipation in which Varieties of 

such a diet does not produce the desired effect. There are, to constipation in 

. P . which the 

begin with, varieties of constipation that are due to anatomic above diet is 
lesions in or about the bowel causing mechanical stenosis, con- co^tra-indi- 
striction, compression or knuckling of the intestine, in which a 
bulky diet that stimulates peristalsis not only is of no value, but 
may be decidedly detrimental. To the same category belong 
cases of venous engorgement of the bowel wall, occurring in 
heart disease, and portal stasis, in which over-loading the bowel 
and irritating its mucosa is decidedly dangerous, as already 
mentioned in another section. In many gastric disorders, or in 
chronic intestinal catarrh accompanied by constipation, such a 
diet again is distinctly contra-indicated. In all these forms of 
chronic constipation the underlying anatomic cause must, there- 
fore, be carefully sought for and a diet arranged according to 
the nature of the primary lesion that produces the constipation. 
The principles that should govern this selection I have described 
in other places. In this variety of constipation the evacuation of 
bowel contents must, in many instances, be promoted artificially 
by means to be presently discussed. 

All the types of constipation mentioned in the preceding 
paragraphs, must be considered either as physiological or as sec- 
ondary to different disorders. In addition many cases of pri- 



446 



CHRONIC CONSTIPATION 



Primary habit- 
ual constipa- 
tion 



Atonic and 
spastic consti- 
pation 

Spastic consti- 
pation 



Causal treat- 
ment 



Symptomatic 
treatment 

Opium and bel- 
ladonna 



Atonic con- 
stipation 



Uses and 
abuses of veg- 
etable-fat diet 



mary, habitual constipation occur and they form the proper sub- 
ject of this section. 

Here it is important to determine whether one is dealing 
simply with insufficiency of the intestinal musculature (usually 
associated with secretory anomalies) or with spasticity of the 
bowel muscles. 

The spastic form of constipation usually develops on the 
basis of various functional disorders of the nervous system, 
notably neurasthenia and hysteria, also in certain organic disor- 
ders of the cerebro-spinal axis and, finally, in certain forms of 
intoxication, chiefly by lead. Causal treatment of this form of 
constipation must be directed primarily against the organic le- 
sions of the brain or cord, that are frequently of syphilitic origin 
and hence may call for antiluetic medication, or against the 
poison that produces the bowel spasticity. In the purely neurotic 
form the same general hygienic, hydrotherapeutic, electrothera- 
peutic and psychic measures that have been described at length 
in the section on the Gastric Neuroses, can be applied, and the 
results obtained from this therapy are generally satisfactory. 

If it is impossible to remove the primary cause, symptomatic 
treatment must be attempted. Here the sovereign remedies are 
opium and belladonna, both drugs that reduce the sensibility of 
the gastric mucosa and, in this way, reduce the reflex spasticity 
of the bowel wall. Paradoxical as it may sound, therefore, opi- 
um, which, as presently will be shown, is one of the chief reme- 
dies in the treatment of diarrhea, becomes in this class of cases 
the most important means of relieving constipation. Laxative 
remedies, massage, irrigation of the bowel, all measures that are 
exceedingly useful in the atonic form of constipation to be pres- 
ently discussed, are directly harmful in this variety. 

Whereas spastic constipation is a comparatively rare disor- 
der, the atonic variety, which is characterized by weakness of 
the bowel musculature, is very frequent and probably constitutes 
the majority of the cases of habitual constipation that are en- 
countered in practice. 

In atonic constipation, as in the alimentary variety, the ad- 
ministration of a vegetarian fat diet generally produces relief. 
This regime should, however, be instituted with some care and 
conservatism ; for, in rare instances, it will be found that the re- 
lief obtained from the institution of such a diet is not permanent, 
and that after a few free defecations, the bowels become consti- 
pated again. This phenomenon must generally be attributed to 
habituation of the bowel wall to the mechanical and chemical 
irritation of such a diet, so that the atonic musculature of the 
bowel after a short time refuses to respond to the stimulus that, 



CHRONIC CONSTIPATION 447 

in the beginning, incited it to increased contractions and forcible 
propulsion onward of the voluminous contents. If this sequence 
of events occurs, then it is wrong to persist in the use of the veg- 
etable-fat diet; for the latter will stagnate in the bowel and in- 
jure the atonic bowel wall both by its bulk and by the irritation 
that emanates from acid and gaseous fermentative decomposition 
products that form from the stagnating material. In such a 
case the evacuation of the bowel contents must, in the beginning, 
often be promoted by other than dietetic means. 

If it is found, however, that, in favorable cases, the diet de- Additions to 
scribed above continues to produce copious daily stools, then above diet 
there may be added to this diet salt foods of different kinds, i. e., 
salt meat, salt fish; for the sodium chloride that these articles Salt foods 
contain draws water into the bowel, or at least, like sugar, pre- 
vents the absorption of a certain proportion of the water from 
the bowel. This self-evidently promotes the liquefaction of the 
bowel contents. In order to further render the stools soft and 
pultaceous abundant liquid should, by all means, be ingested. 
•Cold, plain water or, better still, cold aerated, i. e., carbonated, Abundant 
beverages are very useful and a glass of cold soda water or of wa er 
plain water, taken on an empty stomach, is, in many instances, 
an efficient means to stimulate defecation. Beer, kephyr, sour Beverages con- 
milk and similar beverages containing yeast cells, are also par- taming- yeast 
ticularly useful ; for they aid in the formation of carbon dioxide 
in the bowel from the starchy or sweet pabulum that, as stated 
above, should be administered in abundant quantities. Fruits Juicy fruits 
containing abundant water, especially, therefore, melons, juicy 
pears, apples, peaches, plums, are also valuable in this condition 
and constitute a very convenient means of introducing large 
quantities of liquid together with sugar and fruit acids and a 
certain amount of indigestible cellulose residue. Coffee, in most Coffee and tea 
cases of this kind, acts as a laxative. Tea, on the other hand, Claret 
and claret, on account of the tannic acid they contain, as well 
as chocolate and cocoa, are less useful, in fact, have a tendency 
to constipate. Milk, in the majority of people, produces a con- Milk 
stipating effect. In others, again, it produces diarrhea. Gruels, Gruels 
if the coarse particles are strained off, also constipate and 
should hence be avoided. 

It is necessary, therefore, as will be seen, to experiment a 
little in each case with different articles of food and drink, finally 
selecting a permanent dietary for these cases from the articles 
that are known to produce the desired laxative effect in each par- 
ticular individual. It may be added in parenthesis that smoking Smoking 
a cigarette after breakfast often aids in stimulating peristalsis 
and procuring a good bowel movement. 



448 



CHRONIC CONSTIPATION 



Education 



Massage 



Self-massage 



Hydrotherapy 



Cold sitz 
baths 



An important element in the cure of atonic constipation is 
the education of the patient. An attempt at stool should be made 
at some regular time, preferably a little while after breakfast, 
and if the attempt is abortive for a few days, or if no desire for 
stool is experienced at this time, the effort should, nevertheless, 
be persisted in. On the other hand, the desire for stool at other 
times of the day should be suppressed; for, in this way a suffi- 
cient amount of fecal residue is allowed to accumulate for expul- 
sion at the proper time. 

Massage of the bowel and abdomen is a very important aid 
to the treatment. The main objects of massage are to stimulate 
the peristalsis of the bowel, especially of the large intestine, and 
to mechanically propel the bowel contents onward by forcibly 
kneading and compressing the colon. In order to be effective 
this massage treatment should, for a few weeks in the beginning, 
be carried on daily. It is best conducted in an institution in 
combination with proper hydrotherapeutic means and then, for 
many months afterwards, two or three times a week at home. In- 
asmuch as general abdominal massage, in order to be effective, 
should only be performed by a specially trained expert, and as 
the technique of massage cannot be learned from a verbal de- 
scription, it need not be outlined in this volume. 

A very simple means of self -massage, that I have found high- 
ly effective, is to roll a large wooden ball, of about five or six 
inches in diameter, over the abdomen for five or ten minutes 
every morning. The patient should lie on his back with the 
knees drawn up and should breathe with his mouth open in order 
to relax the abdominal muscles as much as possible. The ball is 
then placed in the right ileo-cecal region and under slight pres- 
sure gradually rolled around the abdomen following the course 
of the colon to the left inguinal region, and then back again to 
the right inguinal region. 

Of hydrotherapeutic measures, aside from those employed 
for the cure of the general neurasthenic or hysteric condition that 
so frequently underlies the atonic as well as the spastic form of 
constipation, the following measures are of particular use in 
overcoming constipation due to atony or abdominal congestion. 

Sitz baths are probably the best measures of all. If they are 
given cold, their first effect is to drive the blood away from the 
abdomen to the upper extremities. Very soon a reactive back 
flow of blood into the abdominal vessels occurs with a resulting 
hyperemia of the bowel wall. This back flow becomes sensible to 
the patient by a feeling of warmth. The reactive hyperemia 
produced in this way is beneficial, inasmuch as it improves the 
nutrition of the bowel musculature and hence aids in overcoming 



CHRONIC CONSTIPATION 449 

muscular atony. A cold sitz bath should last not longer than 
five to six minutes. If the patient leaves the cold water at the 
expiration of this time, the hyperemic effect is prolonged, where- 
as, if the patient remains in the water longer, a secondary condi- 
tion of anemia occurs. 

This secondary anemia can be utilized to advantage in catarrh- 
al disease of the bowel in which it is desired precisely to reduce the 
hyperemia of the intestinal wall. Here, cold sitz baths carried 
out for fifteen to twenty minutes are more useful than short ones 
and exercise a good effect upon the constipation that not infre- 
quently accompanies chronic intestinal catarrh. The effect of 
cold sitz baths can be enforced by having the patient vigorously 
rub the abdomen, legs and back while immersed in the water." 
The best time for giving the sitz bath treatment is late in the Hot sitz baths 
afternoon about an hour before the evening meal. Hot sitz baths 
lasting five to fifteen minutes are also useful inasmuch as the> 
stimulate the whole digestive tract. Their mode of action is not 
so clearly understood as that of the cold baths, and the latter are 
by far more efficacious in overcoming atonic constipation. 

Douching of the abdomen is also useful. The douches should Douching the 
be cool and the water should be directed with considerable force abdomen 
against the abdominal parietes. Cool douches are very stimulat- 
ing and cause contractions both of the external abdominal mus- 
cles and of the muscularis of the intestine ; they combine a ther- 
mic and a mechanical effect. In strong individuals Scottish 
douches are of particular value; they consist in directing an al- Scottish 
ternating stream of hot and cold water against the abdominal douc kes 
wall. The hot stream, combined with the mechanical effect of a 
strong jet of water, causes dilatation of the superficial vessels 
and the cold stream, following immediately afterwards, produces 
a rapid contraction. This change in the calibre of the superficial 
vessels is reflected in the vessels of the internal organs (see also Ether sprav 
page 448). A similar effect can often be exercised by directing a 
spray of ether against the sides or the front of the abdomen. 

Large, cool Priessnitz compresses, especially applied during Priessnitz com- 
the night, are also of great value in overcoming atonic con- Passes 
stipation. They are applied by wringing a linen sheet out of cold 
water, placing it all around the abdomen and covering it with a 
flannel bandage. The water gradually evaporates through the 
pores of the flannel and in the morning the compress will be 
found dry and the skin underneath slightly hyperemic. In win- 
ter it is safer to rub the abdomen with alcohol and a dry towel 
before going out, if the Priessnitz compress has been applied 
during the night. 



450 



CHRONIC CONSTIPATION 



Exercises 



Swedish move- 
ments 



Electricity- 



Irrigation 



Medicated ene- 
mata 

Salt 

Glauber salt 
Soap 
Vinegar 
Castor oil and 
egg 



Passive and active exercises are also useful and any of the 
simpler free-hand exercises that stimulate contractions and 
stretching of the abdominal muscles and compress the liver and 
hence determine a flow of blood to the abdominal viscera, are 
useful. In institutions, Swedish movements answer the same 
purpose. Outdoor sports of all kinds are also very helpful; for 
the increased respiration and deep breathing stimulated thereby 
favor wide excursions of the diaphragm and hence, in a sense, 
constitute a massage of the whole abdominal contents. 

Electricity is of some value in atonic constipation. The most 
convenient way of giving electrical treatment is to perform far- 
adization of the abdominal parietes by the aid of two large 
sponge electrodes that are placed a short distance apart upon 
different parts of the abdominal surfaces. As it is not desired 
by this faradization to produce long tetanic contractions of the 
colonic musculature, the electrodes should be constantly moved 
about, chiefly along the course of the colon, and not kept for any 
length of time in any one place. It is probable that faradization 
of the abdomen acts favorably in constipation more by causing 
vigorous contractions of the abdominal muscles than by its effect 
upon the bowel musculature itself. The galvanic current can be 
applied by the intra-rectal method. Here the same general rules 
apply as in the galvanic treatment of motor insufficiency of the 
stomach. A large sponge electrode should be placed upon the 
abdomen somewhere along the course of the colon, a little water is 
injected into the rectum and a rectal electrode inserted through 
a rectal tube and connected with the anode. Here weak currents 
applied only for three to five minutes are perfectly safe and 
answer all purposes. 

To mechanically clean out the colon and to stimulate peris- 
talsis of the lower bowel, irrigations are exceedingly useful; the 
colder their temperature, the more do they stimulate peristalsis. 
Ice water, however, is rarely used and in some cases hardly safe. 
Small quantities of cool water or of physiological salt solution 
injected into the colon with a high rectal tube answer all pur- 
poses. If it is desired merely to cleanse out the contents of the 
ampulla of the rectum, then lukewarm water is better than cold 
water. 

In order to increase the stimulating effect of cool irrigations 
injected into the higher portions of the large intestine, certain 
chemical irritants can be added to the irrigating fluid, for in- 
stance, common salt or Glauber salt in the strength of two table- 
spoonfuls to the pint ; or soapy water may be used, or a mixture 
of equal parts of vinegar and water. A very useful irrigating 
mixture is a tablespoonful of castor oil beaten with the yolk of 



CHRONIC CONSTIPATION 451 

one egg and mixed with a glass of cold water. This can be in- 
jected through a high rectal tube into the colon and exercises a 
very prompt evacuating effect. 

Glycerin, on account of its hygroscopic properties, i. e., its 
power to draw water into the intestine, may be injected directly 
into the bowel by instillation. If pure glycerin irritates too 
much it should be given in watery solution in the dose of about 
two tablespoonfuls to the quart, and this mixture injected 
through an ordinary fountain syringe; or glycerin supposito- 
ries may be used. Soft stools are usually produced in a short 
time by the use of glycerin. 

Finally, olive oil or sweet oil in the dose of 150 to 500 cc. 
may be injected through a high rectal tube, five to ten minutes ii injections 
being consumed in the process. Oil acts by loosening the pieces 
of feces that are firmly attached to the colon wall, it allays local 
irritation and hence spasmodic contractions of the bowel muscu- 
lature, it prevents water absorption and hence keeps the stools 
pultaceous, and it, finally, leads to the formation of oleic acid, 
which actively stimulates the peristaltic action of the colonic 
musculature. Even if a free evacuation of the bowels occurs 
after an oil injection, a certain quantity of the oil is usually re- 
tained, unless the oil injection is followed by a copious soap and 
water enema. Hence, if no water injection is given, then smaller 
quantities of oil may be injected on subsequent days. If pure oil 
is not retained well, then it may be beaten up with a yolk of egg 
and water, as described above, and five to ten drops of the tinc- 
ture of opium added to the mixture. This irrigating emulsion is 
almost invariably retained without difficulty. 

The chief advantage of using these small amounts of irrigat- 
ing fluid for the purpose of stimulating local peristalsis and me- 
chanically softening the stools, is that the stomach is not irritated 
by the ingestion of laxative purgatives or drastic remedies. 
Large quantities of irrigating fluid are not so safe on account Sma11 a ^ d lar S e 
of the inevitable stretching and relaxation of the atonic bowel 
that they produce. This detrimental effect of large enemata can 
to some extent be counteracted by using irrigations of low tem- 
perature, for the cool water causes contraction of the bowel mus- 
culature and hence neutralizes, to some extent, the mechanical 
stretching of the bowel wall. If it becomes necessary to flush 
out the whole colon, it is best to do this by means of a back flow 
2atheter or by repeated small injections. The best time for irri- 
gating the bowel in chronic constipation, especially if irriga- 
tions are ordered for daily use or several times a week, is imme- 
diately after breakfast. The irrigations should, by all means, 
always be given at the same time of the day. 



452 



CHRONIC CONSTIPATION 



Choice of lax- 
ative 



Alternation 



The different 
groups of pur- 
gatives 



Mode of action 



The haphazard and indiscreet administration of laxatives 
that is so commonly employed in cases of chronic constipation 
is, in most cases, directly harmful to the patient and, at best, be- 
stows only temporary relief. Far from curing constipation, it 
usually aggravates the conditions that it is intended to correct 
and makes the patient a slave to the use of this class of drugs. 

In the spastic form of constipation, as already mentioned 
above, laxatives are rarely needed; in fact, they are usually 
harmful, and opium and belladonna are the proper remedies. In 
the atonic form laxatives should also be given with great care 
and in small doses. If they are given in doses large enough to 
produce a diarrheic stool, then a condition of constipation, as is 
well known, usually follows for several days thereafter, which 
will generally, in its turn, have to be relieved again by large 
doses of a purgative. 

After all the dietetic and mechanical means that have been 
described above fail, then it may become necessary, in rare cases, 
to resort for a time at least to the use of certain laxative drugs. 
It is impossible to predict in any one case which of the many lax- 
atives that can be employed will be effective, and it is necessary 
to experiment a little in each individual. Even if one drug is 
found to be effective for a while, then it is always a good plan to 
alternate from time to time with some other remedy in order to 
prevent habituation to any one laxative. That the smallest pos- 
sible dose to produce the desired effect should be administered in 
these cases need hardly be mentioned. For continued use in 
chronic constipation, either alone or, far better, in combination 
with dietetic and physical measures, I have selected a few reme- 
dies out of the immense number of laxatives that are contained 
in the Materia Medica. These are probably the least harmful and 
the most efficacious in relatively small doses. It is impossible 
to enumerate and describe the dose and administration of all the 
laxatives that are known. For this information I refer to text 
books on pharmacology. 

The vegetable purgatives, i. e., the purgative oils (castor oil, 
croton oil), anthracene purgatives (rhubarb, senna, aloes, fran- 
gulus, cascara and others) and the preparations of the jalapin 
and colocynthin group (colocynth, podophyllum, jalap, elaterin, 
leptandra and others), all act by irritating the bowel mucosa, 
thereby stimulating peristaltic movements of the intestine and 
hastening the propulsion onward of the bowel contents. In this 
way less time is given for the absorption of water from the small 
intestine, and the stools, consequently, reach the colon in a liquid 
or pultaceous form and are promptly evacuated. It is possible 
that these remedies, also, at the same time, cause an increased 



CHRONIC CONSTIPATION 453 

outpouring of watery secretions into the bowel. The character 
of the stool deposited after the administration of these remedies 
will, of course, largely depend upon the dose. Small doses pro- 
duce one or two soft movements, very large doses produce pro- Nomenclature 
fuse, frequent watery evacuations. It is unnecessary, however, and de nitlon 
to retain the old classification into aperient, laxative, purgative,- 
hydragogue cathartic and drastic remedies, the violence of their 
action depending largely upon the dose, not the character of the 
drugs. 

Saline cathartics do not irritate the intestine unless given in Saline cathar- 
very large quantities. They act chiefly by retarding the absorp- 1CS 
tion of water from the bowel and, to some extent, by increasing 
intestinal peristalsis, more on account of their bulk, however, 
than because of any irritating action that they exercise upon the 
intestinal mucosa. In addition, they act as concentrated solu- 
tions of salts tl^at are only slightly diffusible through the bowel 
wall into the blood, and hence, according to the laws of osmosis, 
draw water into the bowel. 

The mercurial purgatives, chiefly insoluble preparations like Mercurial pur- 
calomel (blue pill and gray powder), do not affect the stomach, gatives 
but irritate the bowel, owing to their long sojourn there, which 
leads to their partial conversion into irritating soluble salts of 
mercury. 

In order to produce a mildly laxative effect, cascara, rhu- indications for 
barb, aloes, podophyllin or an alkaline saline are the best reme- J^e use of dif " 
dies for continued use. If large, hard fecal masses have accumu- 
lated in the bowel, these milder remedies are very apt to produce 
griping, so that castor oil, calomel, jalap and colocynth are bet- 
ter. If the patient is in an unconscious state or in a condition of 
mania, so that no medicine can be swallowed, one or two drops 
of croton oil placed on the back of the tongue are more effective. 
In lead colic, too, w r ith obstinate constipation, croton oil, adminis- 
tered as above, is especially useful. Combinations of the vege- 
table purgatives with salines or with bitter tonics are justly pop- 
ular. 

Cascara is best given as the fluid extract, in doses of one-half Cascara 
to one teaspoonful ; or as the wane of cascara, in doses of one to 
two tablespoonf uls ; or as the dry extract, in doses of two to 
eight grains (0.1 to 0.5 gm.). It produces a mild laxative effect 
usually within twelve to eighteen hours after its administration. 
It is, therefore, eminently useful in habitual constipation that 
does not yield to other means, if given every night before re- 
tiring. 

Rhubarb and senna are both old established remedies of tried „, , , 

Rhubarb and 
effect. The chief drawback to the use ^f ^hiibarb is its tendency senna 



454 



CHRONIC CONSTIPATION 



Aloes 



Podophyllum 



Jalap 



Elaterium 



to produce constipation after the evacuation of the bowel con- 
tents has been brought about. It is best, therefore, dispensed in 
combination with a saline cathartic as, for instance, in the com- 
pound rhubarb powder, twenty to sixty grains (1.3 to 4 gm.) ; or 
as the Compound Infusion of Senna (black draught), two to four 
ounces (60 to 120 cc.) ; or as the Compound Mixture of Senna, 
one-half to two fluid ounces (15 to 60 cc.) ; the Mistura Rhei et 
Sodas, two to three ounces (60 to 100 cc.) ; or the Syrups of Rhu- 
barb or Senna, in doses of one to three drachms (4 to 12 cc). 
Senna is more active than rhubarb bulk for bulk. The former 
remedy, however, as well as aloes, to be presently discussed, 
should be given with considerable care in inflammatory disorders 
of the intestine, in renal inflammation and in pregnancy. 

Aloes may be given alone in the form of the extract, two to 
seven grains (0.1 to 0.6 gm.) ; or in combination with rhubarb, 
cascara or senna in pill form; or as the Pil. Aloes, one to five 
pills at a dose; or as the Compound Laxative Pill containing 
aloes, strychnine, belladonna and ipecac; also as aloes contained 
in the Compound Extract of Colocynth, the Compound Rhubarb 
Pill and the Compound Tincture of Benzoin. Any of these 
preparations are useful. 

Podophyllum is especially valuable for continued use in hab- 
itual constipation. It is best given in combination with bella- 
donna as the latter neutralizes, to some extent, the irritation and 
the colic sometimes produced by podophyllum. The effect of 
small doses of podophyllum does not become apparent for about 
twelve hours after its administration, so that it is best given in 
the evening before retiring. Convenient pharmaceutical prepa- 
rations of podophyllum are the Pill of Podophyllum, Bella- 
donna and Capsicum (U. S. P.), and the resin of podophyllum, 
one-quarter to one grain (15 to 60 mg.) in pill form. Podo- 
phyllum is a remedy of varying strength and not always reliable. 

Jalap, too, is best given in pill as the resin of jalap, in doses 
of two to five grains (0.1 to 0.3 gm.) ; or as the Compound Jalap 
Powder, in doses of fifteen to sixty grains (1 to 4 gm.). 

Elaterium may be given as the triturate or the compound 
powder ; the former containing one part of elaterin to nine parts 
of sugar of milk and employed in doses of one-quarter to one 
grain (15 to 60 mg.) ; the latter containing thirty-nine parts of 
sugar of milk and given in doses of one to four grains (0.06 to 
0.25 gm.). 

Neither of the last remedies should be administered continu- 
ously in habitual constipation. They are useful particularly if 
it is desired to produce a rapid evacuation of accumulated feces. 



CHRONIC CONSTIPATION 455 

Sulphur alone, or in combination with rhubarb, magnesia, Sulphur 
or milk sugar, produces a soft, well formed stool. An equal mix- 
ture of precipitated sulphur, powdered rhubarb, sugar of milk 
and magnesia, taken in the dose of a teaspoonful with a glass of 
water every morning and evening, is one of the simplest, least 
harmful and most efficacious remedies for continued use in cases 
of chronic constipation that do not yield to the proper diet and 
to physical means, or that are due to anatomic conditions that 
demand the use of laxative remedies. 

A large number of saline laxatives may be employed in the Saline laxatives 
treatment of chronic constipation. It is a very difficult matter 
to choose among them. The chief members of this group that 
are employed in medicine are the sulphate of soda (Glauber 
salt) and the sulphate of magnesia (Epsom salt), both given in 
doses of thirty grains to one ounce (2 to 30 gm.) in solution, 
preferably in milk. It is important that they should not be 
£ A ven in a greater concentration than about ten per cent. Phos- 
phate of soda is given in doses of fifteen grains to one ounce (1 
to 30 gm.), in the same way as the sulphates of soda and mag- 
nesia. The double tartrates of potassium and sodium (Rochelle 
salts), and the citrates of potassium and magnesium, are both 
given in doses of fifteen to forty-five grains (1 to 3 gm.) in so- 
lution. The oxide and carbonate of magnesia, in doses of five 
to sixty grains (0.3 to 4 gm.) are useful administered in a pow- 
der sweetened with sugar of milk or in one of the combinations 
enumerated above. 

Besides, a number of effervescent laxative salts are given. Effervescent 
The best known of these is the Seidlitz powder. This is made salts 
up in two papers, a blue one and a white one, the former con- 
taining three parts of Rochelle salt and one part of sodium car- 
bonate, in all one hundred and sixty grains (10.4 gm.) ; the lat- 
ter containing thirty-eight grains (2.25 gm.) of tartaric acid. 
The powders are dissolved separately in water and the two solu- 
tions poured together and the whole rapidly swallowed. The 
liquor of magnesia citrate is a solution of magnesium citrate 
with an excess of citric acid and potassium bicarbonate bottled 
tightly; upon opening the bottle effervescence occurs. The dose 
of this solution is five to twelve ounces (150 to 400 cc). 

A great many natural mineral waters containing laxative Laxative min- 
salts are used. The best of these are Hunyadi Janos or Apenta eral waters 
water or Carlsbad water. The action of these waters is due 
chiefly to the sodium or magnesium sulphate they contain. In 
addition they contain a number of inert and less active saline 
constituents. 



456 



Hypodermic 
purgation 



Introduction of 
purgatives by- 
rectum 



The attempt has been made repeatedly to induce purgation 
by the administration of remedies hypodermically. The best 
remedy for this use is apocodeine, which should be given in doses 
of one-twentieth to one-tenth grain (3 to 6 mg.) } dissolved in a 
little water. Besides, aloin, cathartinic acid and citrullin have 
been used, but their administration is very painful and their ef- 
fect is inconstant. Magnesium sulphate injected in small doses 
hypodermically is the latest hypodermic purgative to be intro- 
duced. 

Finally, the administration of purgative remedies may be 
attempted by the rectal route. Colocynth in the dose of 0.1 to 
0.03 gm. ; aloin, 0.4 to 0.5 gm. ; and cathartinic acid, 0.6 gm. dis- 
solved in a little glycerin cause prompt purgation. It is prob- 
able that these remedies after they have been absorbed from the 
rectum are carried to the intestinal mucosa through the blood, 
and act in this way rather than locally. 



Diarrhea in in- 
testinal atony, 
stenosis and 
catarrh 



Daxative diet 
as a prophy- 
lactic 



Diarrhea 
gastrica 



DIABRHEA. 

Diarrhea, in most cases, is a symptom only of a variety of 
primary conditions, the treatment of which has already been 
discussed. Thus diarrhea from irritation of the bowel wall by 
stagnating and decomposing or poisonous (ptomains) bowel 
contents is a common phenomenon in bowel stenosis, in copro- 
stasis and in acute or chronic catarrh of the bowel. Here treat- 
ment must, in all cases, be chiefly directed towards promoting 
prompt evacuation of the offending bowel contents by the ad- 
ministration of castor oil, calomel or the use of bowel irrigation 
as already fully described in the sections on these different dis- 
orders. Besides, of course, the underlying disorder must be at- 
tacked and, if possible, corrected. 

In diarrhea occurring in fecal stasis due to stenosis or intes- 
tinal atony, it is important, contradictory as it may seem, to give 
a slightly laxative diet (see page 444) rather than one that pos- 
sesses constipating properties; for, in this way only can the ac- 
cumulation of fecal matter that directly produces the diarrhea, 
effectually be forestalled. 

An important form of diarrhea (diarrhea gastrica) occa- 
sionally owes its origin to disorders of the stomach, chiefly 
achylia gastrica and motor insufficiency of the stomach or hy- 
peracidity. This variety is closely related to the one mentioned 
above, inasmuch as the food fails to undergo proper disassimila- 
tion in the stomach, and enters the bowel in an insufficiently 
digested or partially decomposed condition, and hence throws 
an abnormal amount of labor on the tryptic functions of the in- 



DIARRHEA 457 

testine, while, at the same time, irritating and overloading the 
canal. This overtaxation and irritation may become so great 
as to produce true catarrli of the bowel with diarrhea, but even 
before this time the intestine periodically gets rid of the abnor- 
mal material which it cannot properly assimilate by diarrheic 
movements. Many of these cases do not apparently suffer from 
the stomach at all, especially if the motor power of this organ 
is unimpaired. At the same time, the primary disorder prob- 
ably lies in the stomach alone and the treatment of the under- 
lying gastric disorder by proper dietetic and medicinal means, 
lavage, etc., generally leads to a cure of the diarrhea. From 
this it will be seen how important it is in every case of chronic 
diarrhea of doubtful origin to carefully determine the state of 
the gastric functions and to arrange treatment accordingly. 

Dyspeptic (or better dystryptic) diarrhea must be included Diarrhea dys- 
in a similar category. Here the bowel irritation, the increased P e P tlca 
peristalsis, the very rapid propulsion of the contents of the 
small intestine into the colon and its prompt evacuation in the 
stools must be attributed to the ingestion of food that is irritat- 
ing or poisonous. In this variety, too, the stomach is usually, 
though not always, affected at the same time. Here, again, the 
chief indication for treatment lies in aiding Nature in its en- 
deavor to rid the bowel of the irritating material; and the prompt 
administration of a dose of castor oil or of some other effective, 
but not too irritating, laxative remedy (see index) combined 
with cleansing of the lower bowel by irrigation, is the proper 
preliminary treatment. The fact that copious and frequent diar- 
rheic stools may have occurred is no contra-indication to the use 
of such remedies; for much offending material will usually still 
be evacuated by their administration and the course of the dis- 
ease materially shortened thereby. To give constipating medi- 
cines in such cases is a gross error (see also the section on Acute 
Catarrh of the Bowel). A little opium and hot applications to 
the abdomen may in persistent cases be required as a sympto- 
matic means to stop very severe abdominal pain. 

To the rarer forms of diarrhea of intra-intestinal origin, be- Diarrhea due 
long, finally, those varieties that are produced by entozoa. That 
the removal of parasites is a sine qua non of successful treatment 
need hardly be mentioned. 

On the borderland between diarrhea produced by the action 
of irritants affecting the bowel from within its lumen and reach- 
ing the bowel through the blood, is the diarrhea seen in a va- 
riety of infectious diseases accompanied by catarrh and ulcera- Diarrhea in 
tion of the intestine. In some of them, notably in typhoid, small- e a S es 10U * 1S " 
pox, sepsis, erysipelas, varioloid, diphtheria, dysentery, anthrax 



458 



Diarrhea due 
to blood-borne 
poisons 



Specific treat- 
ment 



Diet 



Diarrhea in 
uremia 



and tuberculosis, it is often difficult to decide whether the diar- 
rhea is due to local irritation in the bowel and the presence- 
of ulcers or to the action of blood-borne poisons. The fact that 
in typhoid, for instance, profuse diarrhea often occurs long be- 
fore ulcers are present, that, in cholera, no anatomic changes 
of the bowel are generally found despite the most profuse 
diarrhea, that in sepsis, malaria, influenza, pneumonia, similar 
relations are frequently encountered, renders it very probable 
that the diarrheic discharges in all these forms are in great 
part produced by the circulation of specific toxins through the 
bowel wall and the irritation of the intestinal mucosa from 
this source. The treatment of this variety of diarrhea is essen- 
tially synonymous with the treatment of the underlying infection 
and, in most cases, correspondingly successful or unsuccessful. 
If specific remedies are available the diarrhea can usually 
promptly be checked by their use ; thus the diarrhea of malaria 
and diphtheria promptly ceases, as a rule, unless complicated, 
by food poisoning (diarrhea dyspeptica), upon the administration 
of quinine or the injection of diphtheria antitoxin. The clean- 
ing out of a septic focus, the healing of the ulcers in typhoid pro- 
duces the same result without further interference directed to- 
wards checking the diarrhea. The diet, in the latter form of 
diarrhea, need not be modified materially on account of the ex- 
istence of profuse bowel discharges. Whatever food is proper,, 
in consideration of the primary disease, should be continued, 
every effort being put forward to maintain the nutrition of the- 
patient. Fat or coarse irritating foods should be avoided. That 
nourishing semi-liquid and easily digestible foods should be 
given the preference is self-evident. The ordinary fever diet de- 
scribed in the Section on Infectious Diseases of itself answers- 
all these requirements. 

To the class of blood-borne diarrheas, finally, belongs the 
diarrhea of uremia. This is probably caused by the circulation 
of ammonium carbonate which has failed to undergo proper 
conversion into urea. Here, too, appropriate causal treatment 
directed towards restoring the function of the liver (see page 
488f ) and promoting the renal elimination is the most important 
element. This diarrhea must be looked upon as a conservative 
process of disintoxication that it is dangerous to check by consti- 
pating remedies ; for, if this is done, the vicarious elimination of 
circulating urinary end products and of intermediary products 
of perverted metabolism that the kidneys fail to eliminate prop- 
erly is interfered with and the patient is often seriously injured; 
thereby. 



DIARRHEA 459 

The diarrhea occurring in the course of heart disease, espe- Diarrhea in 
cially in the stage of failing compensation, or in portal stasis, is heart disease 
due to the venous engorgement or edema of the bowel wall. 
Here appropriate cardio-tonic medication and the use of those 
means that can correct venous congestion and stasis in the portal 
circulation is the most important element of the treatment. 

In none of the forms enumerated, it will be seen, is the use Remedies 
of constipating remedies, as a rule, indicated. Occasionally opi- 
ates, as already mentioned, have to be administered for the sake opiates 
of producing symptomatic relief. Opiates allay the pain and by 
reducing the violence of peristaltic movements check the fre- 
quency of the bowel discharges, place the bowel wall at rest and, 
in most cases, materially aid in enabling the irritated, usually 
hyperemic, intestinal wall to regain its normal state. In the dys- 
peptic variety of diarrhea, in diarrhea due to coprostasis and in 
nervous diarrhea, to be presently discussed, opium should, how- When pium 
ever, never be given. Its chief sphere of usefulness lies in the should not be 
treatment of catarrhal and infectious types of diarrhea in which 
the evacuation of the irritating bowel contents does not bring 
relief and in which the patients suffer severe pain, and the nu- 
trition is seriously interfered with. Here opium, morphine or 
codeine may be given ; opium, in the form of the extract or the 
tincture, is generally more effective than its alkaloids; for the 
resins contained in preparations of the crude drug favor the 
slower liberation and absorption of the active principles of opium 
and hence grant a more prolonged effect in the bowel. 

Other anti-diarrheic remedies like bismuth, tannin prepara- Bismuth 
tions, lead acetate, silver nitrate, etc., are indicated only in defi- Tannin 
nite anatomic lesions of the bowel, and their use has been dis- Lead acetate 
cussed in full in the part on Acute Intestinal Catarrh (see pages ver m ra e 
413-418). 

Heat, finally, applied to the abdomen, either in the form of Heat 
moist stupes, poultices or cataplasms, or in the form of dry, hot 
cloths, a Leiter coil or a thermophore, or in the form of a Priess- 
nitz or a Winternitz compress (see page 411) is always grateful, 
and distinctly reduces the irritability of the intestine. By re- 
lieving the pain it materially allays the subjective distress of the 
patient and, at the same time, in most cases reduces the num- 
ber of diarrheic discharges. In the symptomatic treatment of 
diarrhea, therefore, immaterial what its cause, it is an invalu- 
able adjuvant. 

There remains for discussion an interesting form of diarrhea Nervous di- 
that must be regarded as a neurosis of the intestine, namely, so- arrhea 
called nervous diarrhea. It may occur acutely in predisposed 



460 



Treatment of 
the neurotic 
individual 



Diet 



Alcohol 



Smoking 

Hest after 
meals 

Arsenic 



Placebo 



neurotic or even in otherwise normal subjects following severe 
psychic or emotional shock, or it may be a chronic recurring 
condition accompanying a variety of organic diseases of the nerv- 
ous system, viz. : Exophthalmic goitre, migraine and the func- 
tional neuroses, hysteria and neurasthenia. In most of the cases 
neurotic manifestations about the vaso-motor sphere, as sudden 
pallor or flushing of the face and neck, or hot flushes, vertigo, 
stupor, palpitation, dyspnea, various psychoses appear together 
with the attack of diarrhea. Nervous symptoms do not, how- 
ever, invariably accompany this form of diarrhea. If it occurs in 
subjects who present no neurotic manifestations, the diagnosis 
can only be made by exclusion ; from the absence, namely, of any 
digestive disorder, from the character of the stools and the pecu- 
liar, often highly bizarre factors that determine the attacks. 

The treatment of nervous diarrhea in a neurotic subject con- 
sists primarily in the use of the general measures applicable 
to the treatment of any neurosis. Here change of scene, a pause 
in the daily routine, life in a resort, a rest cure, suggestive 
treatment and all those hydrotherapeutic and electrotherapeutic 
measures that have been described in full in the section on Gas- 
tric Neuroses, are applicable. In addition any possible reflex 
cause, chiefly about the sexual sphere (in some women nervous 
diarrhea occurs chiefly during the menstrual period) and in 
other regions of the body must be sought for and relieved. 

No special dietetic rules can be formulated for the treatment 
of this form of diarrhea. It will often be found that any 
change of diet is effective for a time. It is probable that here 
the change of regime, possibly following a change of doctors, 
exercises a strong suggestive effect. 

Alcohol should be used with great moderation. It is a pe- 
culiar fact, however, .that in some forms of nervous diarrhea 
that occur immediately after eating, a small glass of brandy or 
liqueur is often efficacious in warding off the attack and also in 
preventing the occurrence of some of the other nervous symp- 
toms described above that frequently accompany the diarrhea. 
Smoking is best prohibited. Sufferers of this kind should be 
advised to lie down for half an hour or an hour after each meal, 
with hot applications to the abdomen. 

Of remedies arsenic is the most popular one, but I have 
never been convinced that it exercises any effect upon the 
frequency of the attacks. A strong suggestive effect is as fre- 
quently exercised by a change of medicine as by a change of diet 
and in some of the cases the administration of a bitter tonic, or 
of any placebo, is, in my experience, fully as efficacious as the ad- 
ministration of any of the remedies that are credited with heal- 



FLATULENCY (METEORISM) 461 

ing powers in this disease. In very extreme eases opium may be Opium 
given in order to check the violence of the peristaltic movements, 
but it should be used with great care in chronic cases because, 
especially in these neurotic subjects, the danger of creating an 
opium habit must always be feared. Bismuth I have found to 
be altogether without effect. 

To the same category probably belongs the peculiar form of Diarrhea fol- 
diarrhea that suddenly follows any exposure to cold or any chill- J^ur? toxoid 
ing of the body surfaces, especially when a draft strikes the neck, 
the feet or the region between the shoulder blades. This variety 
must be looked upon as due to a vaso-motor neurosis and be- 
longs to the same class as vaso-motor coryza. The morning 
diarrhea, coming- on suddenly with one or several profuse watery 
discharges about four or five o'clock in the morning before the 
patient gets up or immediately when the patient gets out of bed 
or puts his feet to the floor, must be looked upon as a nervous 
form of diarrhea, possibly of a vaso-motor origin and produced 
by the change in the temperature of the room in the early morn- 
ing hours or the chilling of the body surfaces when the patient 
leaves the warm bed. Patients suffering from this form of 
diarrhea should avoid any sudden exposure to cold, should, for 
instance, never step on a cold floor when getting out of bed, 
should always wear a flannel binder and appropriate clothing 
and footwear, as described in the section on Rhinitis; they can, 
also to advantage, undergo a hardening process, as described in 
the section on Vaso-Motor Coryza. 

FLATULENCY (METEORISM). 

The causes that can produce this very distressing symptom 
are manifold, and in undertaking to relieve the suffering or dis- 
comfort that accrues from the abnormal accumulation of gas in 
the bowel, the exact cause must be looked for and, if possible, re- 
moved. When this cannot be done, or in cases in which the deter- 
mining factor is chronic and irremediable in character, certain 
measures must be adopted that afford at least symptomatic re- 
lief. In habitual sufferers from flatulency, finally, certain pro- 
phylactic treatment can often be instituted. 

In cases of stenosis of the bowel, in which the normal pas- 
sage of gas through the intestine is mechanically interfered with; to decreased 
in cases of acute diffuse peritonitis, typhoid fever, pneumonia expulsion of 
and certain other infectious diseases in which there is toxic par- 
alysis of the bowel wall ; after abdominal operations, in which 
the manipulation of the intestine or the shock must be incrimi- 
nated with producing intestinal paresis; in general intestinal 



gas 



462 



FLATULENCY (METEORISM) 



Meteorism due 
to increased 
formation of 
gas 



Meteorism due 
to peculiarities 
of bacterial 
flora 



The diet 



Laxatives and 
carminatives 



atony in which there is not paralysis, but merely weakness of the 
intestinal musculature; and, finally, in certain circulatory dis- 
turbances leading to venous stasis and edema of the intestinal 
wall, less gas than normally is expelled from the bowel so that 
it accumulates and produces meteorism. 

In other cases, again, the bowel lumen may be open, there 
may be no muscular insufficiency and a normal or even an in- 
creased amount of gas may be expelled from the bowel, and, nev- 
ertheless, meteorism develop. In such cases flatulency is attrib- 
utable to the formation of abnormally large amounts of gas in 
the bowel. Here evidently one must assume that the intestine has 
been invaded by an exceptionally profuse or especially active 
flora of bacteria or of hyphomycetes capable of producing fer- 
mentation. To this group also belong many of the cases of flatu- 
lency that are seen in catarrhal disorders of the stomach and in- 
testine for here the proper disassimilation of the food does not 
take place while, at the same time, the absence of the normal 
secretions renders the bowel a suitable nidus for various fermen- 
tative bacteria. 

In treating meteorism, therefore, aside from attacking the 
primary cause that creates stenosis, atony or paresis of the bowel, 
the diet must, in every case, be regulated in such a way that espe- 
cially fermentable pabulum and articles of food undergoing fer- 
mentation when eaten, i. e., containing abundant yeast cells, are 
excluded. Thus, vegetables containing much cellulose, like cab- 
bage, peas, turnips, beans, potatoes; fresh bread, cakes, sweets 
of any kind; and of beverages, fresh fermenting liquors and 
drinks containing an abundance of C0 2 , like beer, kephyr, 
champagne, aerated mineral waters, should be excluded. As 
milk in some subjects undergoes rapid fermentation in the 
bowel, it should be stopped if symptoms of flatulency appear 
after its administration. That the diet should, in addition, be 
regulated in such a way as to take into consideration the exist- 
ence of a stenosis or any of the primary diseases that may cause 
intestinal atony, paresis or congestion of the bowel need hardly 
be emphasized. 

Provided there are no distinct contra-indications to their ad- 
ministration (see page 452), laxatives and carminatives are the 
best remedies for causing expulsion of gas that has accumulated 
in the bowel. Laxative remedies, by promoting vigorous peris- 
talsis, obviously aid in the propulsion of gas through the bowel, 
and in addition promptly remove any fermenting material that 
may be stagnating in the intestine. The different laxatives that 
can be employed have been fully discussed in the section on Con- 
stipation. 



FLATULENCY .(METEORISM) 463 

The so-called carminatives comprise a large group of vola- Action of car- 
tile oils and of essences, spirits, waters, tinctures, extracts and minatives 
infusions containing the latter. They are useful only in mild 
■cases of flatulency and are best given in combination with some 
laxative by mouth. Their action is probably that of mild laxa- 
tives and antizymotics. Besides, by mildly irritating the mucous 
lining of the stomach and bowel they produce a pleasant sensa- 
tion of warmth and comfort that often obscures the distress ex- 
perienced from flatulency, consequently their administration 
•causes considerable subjective relief; possible, too, that their 
strong (and usually agreeable) smell and taste stimulates the 
gastro-intestinal secretions and the appetite by a nervous reflex 
route and hence aids digestion like the bitter tonics (see page 
362). Following the administration of carminatives, eructation 
of gas and propulsion of gas into and from the bowel is generally 
produced, and this result would indicate that they actually in- 
crease the movements of the stomach and intestinal peristalsis. 
Whether they aid in promoting the absorption of intestinal gases 
into the blood is questionable. At all events, we know, clinically, 
that they produce marked subjective relief in most cases of flatu- 
lency and hence their administration can be recommended. 

The most common carminatives employed are preparations of Different car- 
cloves, anise seed, caraway seed, peppermint, cinnamon, sassa- amative rem " 
fras, thyme, asafetida, lemon and orange peel, fennel, carda- 
moms, nutmeg, ginger and many others; or the oils themselves 
may be given, singly or combined, or in various combinations 
with bitter tonics and stomachics according to the requirements 
of each case. Teas prepared from the herbs and seeds containing 
these oils are also a very convenient household method of admin- 
istering carminatives. 

In addition to laxatives and carminatives, certain remedies Remedies 
may be administered in flatulency on account of their power to given to bind 
absorb and combine intestinal gases. The chief representative 
of this group is powdered charcoal. On account of its porosity charcoal 
it possesses the power of accumulating gas in its interstices. 
When swallowed it usually holds abundant oxygen. This is lib- 
erated in the intestine, hastening the oxydization of decomposing 
material, while the gases of fermentation are in their turn ab- 
sorbed. It majr be administered as animal charcoal (carbo ani- B }smuth sub- 

,. . * nitrate 

mahs) or as vegetable charcoal (carbo ligni) in powder form or 

in the form of compressed tablets, in doses varying from sixty 
to one hundred and twenty grains (4 to 8 gm.) alone or in com- 
bination with bismuth subnitrate or magnesium oxide. The lat- 
ter remedies are also credited with virtues similar to those pos- 
sessed by charcoal. They bind a certain amount of H 2 S and Magnesia usta 



464 



INTESTINAL PARASITES 



Physostigmine 



Colonic irriga- 
tion 



Rectal tube 



Massage of the 
abdomen 



Hot applica- 
tions and lini- 
ments 



Puncture of the 
bowel 



C0 2 chemically with the formation of sulphids and carbonates 
of bismuth and magnesium. 

Physostigmine (eserine) salicylate, in the dose of a one hun- 
dred and twentieth to a sixtieth of a grain (0.0008 to 0.016 gm.) 
in pill form, or hypodermically, given two or three times a day, 
has been recommended by von Noorden for meteorism due to in- 
testinal atony or paresis. The drug in such small doses can do 
no harm and its administration is worthy of a trial. 

Irrigation of the colon with cool enemata by stimulating per- 
istalsis often aids in the expulsion of gas from the lower bowel. 
The addition of a tablespoonful or two of some carminative wa- 
ter, or of a few drops of oil of turpentine, to the enema is often 
helpful; or a long rectal tube may be introduced into the colon 
and kept in place for some time; in this way much gas some- 
times escapes. Aspirating the gas from the lower bowel with an 
aspirating syringe is usually superfluous. 

Gentle massage of the abdomen performed for the purpose of 
stimulating peristalsis, especially in the colon, may be practised 
to advantage, provided no contra-indications to manipulation of 
the abdomen, as stenosis, ulceration, intestinal paralysis, exist. 

Hot applications are best of all to relieve distress Turpen- 
tine stupes may be applied and sometimes aid in producing re- 
lief. Various liniments (see page 334) applied to the abdomen 
are also occasionally effective in relieving the subjective distress 
of the patient until the expulsion of gas can be promoted. 

In extreme cases, and as a precarious emergency measure,, 
puncture of the distended coils of the intestine with a needle tro- 
car (see page 435) may be attempted in order to allow the escape 
of some of the gas from the bowel. 



Contra-indica- 
tions to tape- 
worm cure 



Preliminary 
treatment 



INTESTINAL PABASITES. 

Tape-worm. — Tcenia solium, Tcenia mediQcanellata, both- 
riocephalus latus). In the presence of gastro-intestinal ca- 
tarrh, great debility, pronounced anemia, chronic alcoholism, 
serious cardiac or renal lesions, a tape-worm cure should always 
be instituted with great care. During pregnancy, the puerperium, 
lactation and during the menstrual period, a tape-worm cure is. 
best not instituted. Very little children (status tliymicus!) and 
very old people seem to stand badly the rigorous treatment nec- 
essary in order to expel a tape-worm. 

In instituting a tape-worm cure the patient 's intestine should 
be thoroughly emptied as a preliminary measure. This is accom- 
plished by practically starving the patient for twenty-four 
hours, allowing only a little milk, coffee, some soup and plenty 



INTESTINAL PARASITES 465 

of water on the day before. The main object of this preliminary 
starvation is to deprive the tape-worm of the protection from 
the remedy he obtains if mnch fecal matter is present in the 
bowel. This object is further accomplished by administering a 
brisk purge, either castor oil or calomel, on the evening before 
the administration of the anthelmintic, followed in the morning 
by one or two rectal injections, provided profuse evacuations of 
the bowel have not been produced. 

Four remedies in particular are efficacious in promoting ex- Aspidium 
pulsion of the tapeworm, viz. : Male fern (aspidium felix mas) ; Granatum 
pomegranate (granatum) and pelleticrinc, a mixture of several e letierme 
of the alkaloids of pomegranate; pumpkin seed (pepo); cusso 
(bray era anthelmintica) . 

These remedies are all given on an empty stomach in the fol- 
lowing dosages : 

Male fern, as the oleo resin, in the dose of one-half to two Male fern 
fluid drachms (2 to 8 cc), or as the liquid extract, in the dose 
of forty-five to ninety drops, preferably in a gelatine capsule. 
One hour after the drug is swallowed a purge is given, either 
the compound infusion of senna, in doses of four ounces, or two 
or three grains of calomel, followed within an hour by a table- 
spoonful of magnesia sulphate in a glass of water. Castor oil 
is not so useful, as poisoning from aspidium seems to occur more 
commonly if castor oil is given than if one of the other purga- 
tives is administered. If within two or three hours after the 
administration of the purge the desired effect is not produced, a 
large colonic irrigation of normal salt solution should be em- 
ployed ; this will usually bring the worm away. If only links are 
secured, but no head or heads, a second or a third irrigation 
should be practised. If this first attempt to expel the tape-worm 
is not successful, at least a week or two should be allowed to 
elapse before a second tape-worm cure is undertaken. 

Some patients become very much nauseated or even vomit 
after they have taken the medicine. This effect can often be 
prevented by having them lie down and chew small pieces of 
lemon or orange peel or take peppermint drops, or swallow small 
ice pills, or teaspoonful doses of ice tea or ice coffee. 

Pomegranate is best given as pelletierine in doses of two to Pomegranate 
four grains (0.12 to 0.25 gm.) in capsule or pill; or one to two 
ounces (32 to 64 cc.) of the decoction (decoct, granatce cortex) 
in 250 cc. of water, taken in two portions, one hour apart, may 
be given ; as the latter preparation is very disagreeable and bitter 
to the taste, it is best administered together with some flavor- 
ing syrup. 



466 



INTESTINAL PARASSiTES 



Pumpkin seed 
Cusso 

After treatment 
Hound worm 

Santonin 



Santonin 
poisoning 



Xanthopsia 



Spigelia 



Oil of cheno- 
podium 



Pumpkin seed is given in the dose of two to three ounces (64- 
96 gm.) of the powder suspended in an emulsion or made into a 
paste with sugar, molasses or honey. 

Cusso is administered by suspending half an ounce (15 gm.) 
of the powdered flowers in water. It is not so efficacious as the 
other preparations. 

The after treatment by purging and irrigating is the same, 
immaterial which of the vermifuges is employed. 

Round Worm. — (Ascaris lumbricoides.) Here, too, as in the 
case of the tape-worm, a preliminary starvation and purgatiors 
treatment should be instituted. 

The most trustworthy remedy to promote the expulsion of 
round worm is santonin. This medicine is best administered in 
the form of troches (Troch. Santonin U. S. P.), in the dose of one 
lozenge for a child, two for an adult, each lozenge containing 
half a grain of santonin ; or the remedy may be given in solution 
in castor oil, but less of the remedy seems to be absorbed from 
the stomach if given in this menstruum than if given in tablet 
form. Three or four hours afterwards an active purge should be 
used to carry off the parasites. 

In some persons toxic symptoms appear, namely, muscular 
twitchings about the head, rolling of the eyes, grinding of the 
teeth, even epileptiform convulsions, mental confusion, nausea, 
vomiting and xanthopsia (yellow vision). The last named symp- 
tom occurs in most people after the administration of santonin. 
It need cause no alarm for it usually passes off quickly without 
any further treatment. It is best, however, to call the attention 
of the patient to the possible occurrence of this phenomenon. The 
appearance of the other signs mentioned above, which indicate 
intoxication of the central nervous system, calls for prompt evac- 
uation of the gastro-intestinal contents by emetics and purges. 
The spasms, if they are severe, may be controlled by chloroform 
or ether inhalations. 

Spigelia is another useful remedy to expel round worms. 
It should be given as the fluid extract, in doses of a teaspoonful 
(4 cc.) to a child, two teaspoonfuls (8 cc.) to an adult, fol- 
lowed by full doses of the infusion of senna, castor oil, or mag- 
nesium sulphate; or it may be administered in the form of the 
fluid extract of spigelia and senna, in three doses, of one tea- 
spoonful each, given two hours apart to a child, in three doses 
of two teaspoonfuls given at the same interval to an adult. 

Still another remedy that is occasionally efficacious and that 
may be mentioned for the sake of completeness, is the oil of 
chenopodium. It should be given in doses C"f five to ten drops 



INTESTINAL PARASITES 467 

(0.3 to 0.6 gm.) in an emulsion or on sugar followed by a purga- 
tive. 

Thread Worms. — (Oxyuris vermicular is.) This parasite Thread worms 
finds its chief habitat in the large intestine, especially in the 
rectum, although, as a rule, the worms are also found in the small 
intestine. The parasite must, therefore, be attacked both by 
mouth and by rectum. Sufferers from thread worms should, Santonin 
therefore, receive santonin or spigelia, given in the same manner pi8>e ia 
and dose as described above in the treatment of round worm, 
followed by a purge. In this way the parasites contained in the 
small intestine are destroyed or propelled into the large intestine 
where they can be attacked by the rectal route. 

The chief attention, however, should be directed towards rid- 
ding the lower bowel of the parasites by large medicated injec- 
tions. The best medicine of all is the infusion of quassia made by Infusion of 

Quftssis 
-adding one or two ounces (32 to 64 gm.) of quassia chips to a 

pint (500 cc.) of water and injecting the whole quantity, under 
-considerable pressure, after a preliminary cleansing of the bowel 
with a copious warm soap and water enema. An attempt should 
be made to hold this injection for about five minutes. In very 
little children a cotton plug may be pressed against the anus in 
order to aid the child in retaining the medicine. Generally these 
injections must be repeated a number of times and on successive 
<iays and frequently at intervals for weeks. Sufferers from 
thread worms should be particularly careful to keep the hands 
and finger nails clean and free from contact with the rectum, as 
the parasites, and especially their minute eggs, may otherwise be 
-carried from the rectum to the mouth, and in this way reinfect 
the patient. 

Remedies other than quassia that are employed for attacking vinegar 
the thread worms in the lower bowel are vinegar in the dose of Sublimate 
two tablespoonfuls to a litre of water; corrosive sublimate 0.01 Naphthalin 
to 100, naphthalin or thymol, each in the strength of one part to ym ° 
one hundred of olive oil. 

The violent pruritus ani that frequently tortures sufferers Pruritus ani 
from thread worms can usually be controlled by smearing blue 
ointment around the anus or by inserting a suppository contain- 
ing from 0.1 to 0.2 gm. of blue ointment into the rectum. 

The best remedy for anchylostoma and uncinaria* is thymol. Anchylostoma 
After a preliminary cleaning out of the intestinal tract by starv- Uncinaria 
ation, purgation and irrigation, the drug should be given in gela- Thymol 
tin capsule or emulsion in large doses, namely thirty grains (2 
gm.) repeated every two hours for three or four doses, and fol- 



♦Amoebic Dysentery, see under Infectious Diseases. 



468 



ACUTE DIFFUSE PERITONITIS 



lowed five hours after the last dose by a brisk purge. If a first 
course of this kind does not cause the disappearance of the para- 
sites, a second or a third thymol treatment may be given. 



Perforative 
peritonitis 



Shock no con- 
tra-indication 
to an operation 



Acute diffuse 
peritonitis a 
surgical dis- 
ease 



Object and lim- 
itations of in- 
ternal treat- 
ment 



IV. THE PERITONEUM. 
ACUTE DIFFUSE PERITONITIS. 

Acute, diffuse peritonitis following intestinal perforation^, 
provided the patient is seen within the first ten hours after per- 
foration has occurred, calls for an immediate laparotomy. While 
an occasional spontaneous cure of perforative peritonitis is re- 
corded, it is decidedly bad practice to count on this remote possi- 
bility and to refrain from an operation ; for without an operation 
the patient is practically doomed, with an operation he has a 
chance, though a small one, of recovery. The earlier the opera- 
tion is performed, the better; for in perforative peritonitis the 
point of perforation may be discovered and closed up and thus 
further contamination of the peritoneal cavity prevented; be- 
sides, free drainage is thereby established and the peritoneal cav- 
ity rid of a good deal of toxic material. 

The preliminary shock often following perforation is no con- 
tra-indication to the operation. The development of secondary 
shock and collapse that is often seen in the later stages of diffuse 
septic peritonitis, renders the outlook more precarious, but it does 
not apparently render the prognosis altogether hopeless, so that 
here, too, a laparotomy should generally be performed. 

If the symptoms of a general toxemia are not very pro- 
nounced, and if the local symptoms about the abdomen are most 
prominent, the chances of improvement or recovery from drain- 
age of the peritoneal cavity by laparotomy are not bad. 

Acute, diffuse peritonitis, then, in the light of our present 
knowledge, is essentially a surgical disease. Internal measures- 
offer very slight chances to the patient and until serum therapy 
shall have given us a remedy to combat the bacterial toxemia, the 
efforts of the medical man must be directed principally towards 
forestalling the occurrence of peritonitis and towards preventing, 
so far as that is possible, an extension of the process or an aggra- 
vation of the condition in cases that cannot be operated upon 
promptly. Finally, internal treatment should be directed to- 
wards supporting the patient's strength in every way in cases 
that cannot or will not be operated upon, in the feeble hope that 
spontaneous recovery may after all occur. An optimistic atti- 
tude, even in apparently desperate cases, can assuredly do no 
harm, and if nothing more is accomplished, the unhappy victim 
may at least be rendered comfortable and saved the excruciating. 



ACUTE DIFFUSE PERITONITIS 469 

tortures of body and mind that usually precede death from this 
horrible disease. 

A patient with acute, diffuse .peritonitis should be kept per- Rest 
fectly quiet. Most cases endeavor to do this spontaneously. 
Here and there, however, the pain is so great that the sufferers 
thrash around in bed trying to find a comfortable position. In 
such cases opium or morphine may be needed to enforce quiet, opiates 
The best position for the patient to occupy is the dorsal with 
the head of the bed elevated in order to promote drainage to- 
wards the pelvic region, which is apparently more resistent to 
pus than other areas of the peritoneum. As a rule the patient 
will lie on his back with the legs drawn up. This position, if 
not spontaneously occupied, should be encouraged, and the legs, 
if needed, supported by pillows or by a support placed under- 
neath the knees. 

Kest of the bowel should be secured by all means. Active Rest of tlie 
peristaltic movements prevent closure of the perforation and bowel 
sealing of the perforative opening by peritoneal adhesions, favor 
spreading of bacteria through the peritoneal cavity and, above 
all, increase the pain. Intestinal rest should be secured as de- 
scribed in detail in the section on Circumscribed Peritonitis by 
a total abstinence from food during the few days of the disease, Total absti- 
by refraining from the use of any laxative remedy, by avoiding nence from 
rectal irrigations or rectal feeding and by employing opium. Opi- 
ates act as favorably on the subjective symptoms of the patient 
as in the circumscribed variety (dose and administration, see Opiates 
page 476f), by allaying the pain and by inhibiting many of the 
reflexes attributable to this factor, namely, vomiting, hiccup, 
restlessness and, to some extent, shock. 

Another very useful effect of the opiates, finally, in view of Thirst 
the danger in this disease of giving anything, even water, by 
mouth, is their power to allay the distressing thirst that often 
tortures these patients. The thirst can, furthermore, be con- 
trolled by allowing the patients to suck small pieces of ice with- 
out permitting them to swallow the water. 

The water demands of the organism may be supplied by Subcutaneous 

the injection of normal salt solution by hypodermoclysis or and l nt . r „ a y en ~ 

ous fluid m- 
mtravenously (technique, see index). Large quantities of fluid jections 

may be used for this purpose, as distinct advantages seem 

to accrue to many cases of diffuse peritonitis from this practice; 

for the blood pressure is raised thereby and the heart stimulated. 

It is possible, too, that the injection of abundant liquid under 

the skin and into the circulation dilutes the toxins and promotes 

their elimination from the body. Finally, the injection of large 

quantities of fluid directly into the blood vessels prevents, to 



470 



ACUTE DIFFUSE PERITONITIS 



Local applica- 
tions 



Inunctions 



Symptomatic 
treatment 



Initial col- 
lapse 

Vomiting 



Hiccup 



Meteorism 



Cardiac fail- 
ure and col- 
lapse 



some extent, the absorption of toxins from the peritoneal cavity, 
seems, in fact, to determine an outpouring of fluid into the peri- 
toneal cavity. In some hospitals very large quantities, as much 
as ten to fifteen pints, of salt solution, are infused or injected 
in this way in every case of acute, diffuse peritonitis, even as a 
preliminary to an operation for diffuse peritonitis, and remarka- 
bly good results are reported from this plan. The method, 
therefore, is certainly worthy of trial, not only as a means to 
quench thirst and to maintain the water equilibrium of the body, 
but even as a curative agent. 

Very little can be expected from local applications. Neither 
continuous nor interrupted applications of cold exercise any de- 
terminable influence on the course of the disease. One must be 
guided in making applications to the abdomen by the sensations 
and the desires of the patient, and apply either heat or cold in 
that form that brings the most relief. Inunctions of the abdom- 
inal surface with gray ointment or with other counter-irritant 
salves is no longer practised. It is hard to understand how any 
measure of this kind can do good. 

For the symptomatic treatment of acute, diffuse peritonitis, 
opiates and heart tonics are the best remedies. The former, as 
stated above, relieve the pain, the restlessness, the vomiting, the 
hiccup and, at the same time, deaden the sensitiveness of the 
peritoneal nerves and hence effectively counteract the tendency 
to initial collapse. 

For the vomiting, provided it is not controlled by opiates, i. 
e., either opium given by mouth or morphine administered hypo- 
dermically, a few drops of chloroform on ice or a teaspoonful of 
ice cold chloroform water or a dilute cocaine solution adminis- 
tered in frequent doses (see page 19) may be given. Priessnitz 
compresses applied to the epigastric region are sometimes an 
effective counter-irritant that controls the vomiting. 

Hiccup can occasionally be controlled by small doses of atro- 
pine — a one hundred and twentieth to a fortieth of a grain 
(0.0005 to 0.0015 gm.), given either by mouth or hypodermically. 
This remedy is to advantage used in combination with a quarter 
of a grain (0.015 gm.) of morphine hypodermically, two or three 
times in the twenty-four hours. 

Meteorism, if it seriously interferes with respiration and the 
action of the heart by pressure upon the diaphragm, is best con- 
trolled by the insertion of a soft rubber catheter into the rectum, 
which aids the expulsion of the gases. More active measures de- 
scribed in the section on Meteorism are hardly ever applicable. 

If signs of heart weakness or collapse appear after the dis- 
ease has persisted for some days, if the pulse is rapid and of a 



ACUTE CIRCUMSCRIBED PERITONITIS — APPENDICITIS 471 

low tension, then digitalis may be given in the dose of five drops 
of the tincture every few hours. Better still is adrenalin chlo- Digitalis 
ride, hypodermically, in doses of ten to thirty drops of a 1 :1000 
solution and repeated until the effect on the blood pressure be- Adrenalin 
comes apparent ; or adrenalin in the above dosage may be added 
to the large saline infusions that have been spoken of. In serious 
heart failure coming on suddenly the ordinary analeptics, caf- Analeptics 
fein, camphor, ether, ammonia (see page 32) may have to be em- 
ployed. Alcohol, too, in the form of strong spirituous liquors, Alcohol 
given by mouth or injected in dilute form into the rectum, may 
serve a similar purpose. Alcohol seems to be particularly useful 
in profound sepsis that threatens to produce heart collapse. 

ACUTE CIRCUMSCRIBED PERITONITIS, 
PERITYPHLITIS, APPENDICITIS. 

So far as the treatment is concerned, inflammatory and sup- classification 
purative processes about the appendix and the peritoneum of the 
ileo-cecal region cannot very well be separated, especially as most 
cases of perityphlitis originate from appendiceal inflammation 
and as cases of appendicitis rarely run their course without some 
inflammation of the pericecal tissues. The treatment of acute 
circumscribed peritonitis in other areas of the abdomen does not 
differ from that of perityphlitis. 

Internal therapy, which essentially means an expectant plan 
of treatment with rest and the avoidance of all agencies that can 
produce local irritation, is successful in a large proportion of 
cases. In other cases surgical intervention is imperative from 
the onset of the affection. In still other cases it is good practice 
to wait for definite indications before advising surgery, and, a 
last, fortunately small group of cases, run a rapidly fatal course 
uninfluenced in any way by internal or surgical treatment. 

In the management of a case of appendicitis the most diffi- When to op- 
cult task is, therefore, to determine whether to operate and when erate 
to operate; to decide whether it is safe to await further devel- 
opments before placing the patient on the operating table, or 
whether it is necessary to order surgical intervention at once in 
order to save life. 

The operative treatment of appendicitis has, without doubt, Critique of 

reduced the mortality from this disease. While the death rate sur gical 

statistics 
from surgery, when the operation is performed by skilled and 

experienced surgeons supported by all the facilities of a modern 
hospital, is low, the surgical death rate is far higher in country 
communities, where an operation has to be performed at the pa- 
tient's house, without trained attendants and by a general prac- 



472 



ACUTE CIRCUMSCRIBED PERITONITIS — APPENDICITIS 



Conditions 
calling for sur- 
gical treat- 
ment 



Abscess 



Intestinal ob- 
struction 



Acute perfora- 
tive peritonitis 



Diffuse peri- 
tonitis 



Subacute fibro- 
purulent peri- 
tonitis 



Indications for 
surgical in- 
tervention 



titioner who constantly comes in contact with septic cases and 
whose experience is, of necessity, limited. Under the latter cir- 
cumstances (and in this large country of ours, conditions such 
as those described are very general), the mortality would proba- 
bly be lower if no cases were operated than if surgical interven- 
tion were practised in every case, as some surgeons advise. The 
voluminous statistics in favor of the operative treatment of ap- 
pendicitis that emanate from large surgical hospitals, and the 
arguments adduced from these statistics by the master surgeons 
operating in each of these clinics, are consequently not applica- 
ble to practical conditions encountered in everyday medical life 
in smaller communities. 

The following conditions by all means call for prompt surgi- 
cal intervention: 

1. PeritypMitic or appendiceal abscess. This must, of neces- 
sity, be opened and drained. It is true that spontaneous rupture 
of such an abscess through the skin or into the bowel may occur, 
but, in view of the much greater probability of such an abscess 
rupturing into the peritoneum, it is an exceedingly precarious 
matter to forego surgical treatment. 

2. Intestinal obstruction. Here surgery in most cases is the 
only means of cure. If the obstruction is due to bowel paresis 
occurring in the course of diffuse septic peritonitis, even surgery 
is in most cases unable to help and these patients die with or with- 
out an operation. 

3. Acute perforative peritonitis. Here an operation per- 
formed without delay is sometimes life-saving, although, even in 
this emergency, a few instances are on record in which the pa- 
tient recovered without an operation. 

4. Cases of diffuse peritonitis of one or two days' duration. 
These should be given the benefit of an operation; for, while 
most of these patients die even if a laparotomy is performed, the 
patient is assuredly doomed (with some doubtful exceptions that 
are scattered through the literature) unless the abdomen is 
opened. 

5. Sub-acute fibro-purulent peritonitis. These cases offer an 
excellent field for surgical intervention. "The majority of cases 
of diffuse peritonitis cured by surgery belong to this category." 
(Nothnagel.) 

Valuable indices to guide the physician in regard to the ad- 
visability of operative interference in cases of appendicitis and 
perityphlitis are, the course of the temperature ; the fluctuations 
in the pulse rate; the pain; the fluctuations in the number of 
leucocytes and the character of the tumor. By means of these 
clinical signs the presence or absence of pus can usually be diag- 



ACUTE CIRCUMSCRIBED PERITONITIS — APPENDICITIS i73 

nosed and indications for and against surgical intervention in 
general be formulated. 

The temperature, as a rule, depends on the character and the Temperature 
virulence of the bacteria causing the infection. A high temper- 
ature, i. e., 103° F. and over, persisting until or after the fourth 
day, generally indicates a virulent type of infection. A high 
temperature at the onset of the attack, even when accompanied 
by a chill, but disappearing by the end of the third day, may 
occur in simple catarrhal inflammation of the appendix and, 
alone, constitutes no indication for surgical intervention. Rela- 
tively low temperatures of 101 or 102°, persisting after the fifth 
or sixth day of the disease, render a laparotomy advisable, espe- 
cially if at this period the temperature, instead of gradually 
dropping, rises and fluctuates rapidly within several degrees. 
A rapid fall of the temperature at any time of the disease should 
put the physician on the alert for perforation and acute diffuse 
peritonitis. It is well to remember that sometimes a large ab- 
scess due to the presence of bacteria that are only slightly viru- 
lent may have formed and the temperature still remain low or 
normal. Here other signs than the fever must be the main guide 
to the diagnosis and the low temperature self-evidently consti- 
tutes no contra-indication for an operation. In view of the great 
importance of the temperature curve in rendering a diagnosis in 
regard to the exact conditions present, it is clear that antipyretic 
drugs should never be given in appendicitis; for their adminis- 
tration obscures one of our most important clinical indices. 

A small, rapid, soft, pulse, especially when associated with The pulse 
a relatively low temperature, signs of cyanosis, cold extremities, 
cold sweats and diffuse sensitiveness over the whole abdomen is 
often indicative of acute diffuse peritonitis. A rapid, bounding, 
full pulse, on the other hand, associated with a correspondingly 
high temperature, severe and strictly localized pain, particularly 
within the first two or three days of the disease, is not necessar- 
ily an indication for a laparotomy, and it is usually safe to treat 
such cases, under careful supervision, by internal means. A 
sudden change in the volume and the tension of the pulse, of 
course always constitutes a serious warning of impending danger. 

The pain is a very unreliable symptom and one that I am rphe p a i n 
in the habit of neglecting when attempting to arrive at a deci- 
sion in regard to the advisability of operating. Especially if 
the opium treatment is employed (see below) the pain is dulled 
and this symptom eliminated from consideration altogether. 
Moreover, very mild attacks of appendicitis may be accompanied 
by very severe pain, and exceedingly grave attacks by slight 
pain or no pain at all. Very much will depend on the individual 



474 



ACUTE CIRCUMSCRIBED PERITONITIS — APPENDICITIS 



The leucocytes 



The tumor 



Difficulties of 
arriving at a 
decision 



Advantages 
and disadvan- 
tages of surgi- 
cal and medi- 
cal treatment 



sensibility of the patient, the presence or absence of much fecal 
material causing distention of the bowel and other quite uncon- 
trollable elements. A very severe sudden pain in the ileo-cecal 
region should, of course, always arouse the suspicion of a per- 
foration. Gangrene of the appendix, one of the most dangerous 
complications, is often accompanied by very slight pain or no- 
pain at all; for "a dead appendix feels no pain." 

If the examination of the blood shows a high degree of poly- 
nuclear leucocytosis, increasing steadily, this generally indicates 
pus and renders a laparotomy advisable. Too much reliance 
should not, however, be placed upon this sign; for very serious,, 
distinctly surgical forms of appendicitis are encountered in 
which this progressive increase in the number of leucocytes does 
not occur.* 

A steadily growing tumor in the ileo-cecal region, or a swell- 
ing the size of which remains stationary after the fourth or 
fifth day of the disease, especially when associated with 
a high, persistent fever, and an increase of the leu- 
cocytes, in most cases indicates an abscess and calls for surgical 
intervention. If leucocytosis and a high fever are absent, and if 
the tumor is not especially painful, a preliminary irrigation of 
the colon with small amounts (200 cc.) of lukewarm water may 
safely be attempted and the tumor, if it is fecal in character,, 
will sometimes promptly disappear under this treatment, the 
temperature drop and the meteorism vanish. I have never con- 
sidered it safe, under any circumstances, however, to give an in- 
ternal laxative on the suspicion that the tumor might be fecal 
in character, especially if there was much fever and a high leu- 
cocyte count. 

It will be seen, therefore, how exceedingly difficult it is to 
arrive at clean cut indications for surgical intervention in this 
disease. No absolutely fixed rules for or against an operation can 
be set down, and each case must be judged separately. On the 
one hand, as stated above, an apparently simple case may lead to 
perforation or gangrenous rupture of the appendix with acute 
peritonitis; on the other, an apparently very severe case may 
progress toward complete resolution without surgical interven- 
tion. Here and there a case would have been saved had an oper- 
ation been performed at once. Here and there, on the contrary, 
a case would have lived had operative interference not been at- 
tempted, for the administration of an anesthetic, the excitement, 
the fear and the shock of an operation, not to speak of the diffi- 



*The clinical significance of a sudden drop in the leucocytes is not 
clearly established. 



ACUTE CIRCUMSCRIBED PERITONITIS — APPENDICITIS 475 

cult manipulation of an inflamed, or adherent or fragile appen- 
dix or cecum, are by no means negligible elements. If the case, 
moreover, heals without an operation, convalescence is more rap- 
id and there remain none of the disagreeable sequelae of fecal 
fistula, broad adhesions, etc., that may follow any laparotomy 
performed during the acute stage of appendicitis or perityphlitis. 
I am inclined to the belief that more cases are destroyed by un- 
necessary surgical intervention, especially in country practice, 
than would be sacrificed for lack of an operation, particularly if 
the proper internal treatment to be now described is instituted 
and the patient is very carefully watched all the time for the ap- internal treat-- 
pearance of definite surgical indications. ment 

Complete rest of the patient is one of the most important ele- 
ments of the treatment. The patient should remain on his back 
with the right leg drawn up and preferably supported under the Rest of the 
knee by a pillow or two ; the body should be slightly raised or the P atient 
whole head of the bed elevated; in this way drainage into the 
pelvis is promoted in case perforation should occur. This is an 
important element, because the pelvic peritoneum, especially in 
women, is singularly resistent to pus infection. The patient 
should not be allowed to get up under any circumstances, nor 
should he be permitted to perform any violent movements in bed. 
Defecation and urination should be performed with the aid of 
the bed pan and the urinal, and the patient should be lifted upon 
the bed pan by attendants and not allowed to raise himself. The 
patient should remain in bed for at least five to ten days after 
the disappearance of all acute symptoms, the fever and local 
signs. If these precautions are not carried oat, delicate perito- 
neal adhesions that are thrown out in the inflamed area are apt 
to be torn and dangerous complications engendered thereby. 

The intestine, too, should be placed completely at rest. If Rest of the i»* 
there is nausea or vomiting, complete abstinence from food for testine 
one, two or three days is a very good plan. As the patients gen- Abstinence 
erally become very thirsty under this total abstinence, small rom 00 
pieces of ice may be sucked or the mouth may be frequently Thirst 
rinsed with some antiseptic solution, a little peppermint water or 
soda water, or the patient may be allowed to chew a little gum. 
In some cases water, given in teaspoonful doses every hour or 
so, can, however, do no harm, as all of the water is absorbed in 
the stomach or in the first part of the intestine, and as the in- 
gestion of water only very slightly stimulates bowel peristalsis. 

After forty-eight hours, provided there is no more vomiting, Diet during 
a little milk, in doses of a tablespoonful or two, may be admin- first days 
istered every two or three hours, or a little meat broth with an 
egg stirred into it, or some thin, strained gruel made of boiled 



476 



ACUTE CIRCUMSCRIBED PERITONITIS APPENDICITIS 



Diet after a 
week 



Nutritive ene- 
mata and 
bowel irriga- 
tion 



Opium 



Objections to 
opium 



Advantages of 
opium 



milk and barley, wheat, oatmeal flour or sago, arrowroot, tapioca 
may be permitted in small doses. If milk is distasteful to the 
patient or is not well borne, especially if it produces flatulency, 
it should be stopped and gruel made of water and the above 
flours, soups and broths alone should be given. 

After a week or ten days, provided all acute symptoms have 
disappeared, a soft boiled egg, some mashed potatoes, some vege- 
table purees, a little very finely chopped sweetbreads, chicken or 
mutton, may be administered, and, then, very gradually, a solid 
mixed diet resumed, omitting all those articles from the bill of 
fare that contain spices or condiments, that produce much fer- 
mentation in the bowel or that leave a coarse, indigestible 
residue. 

Nutritive enemata are rarely required and best avoided alto- 
gether. The injection of lukewarm water into the lower bowel 
for the purpose of supplying some water to the body is rarely 
necessary during the first few days, especially if the patient is 
allowed to take a little water by mouth, as indicated above ; in 
fact, the injection of fluids into the rectum is, in most cases, a 
somewhat precarious procedure and one that is best avoided. 
Later in the disease and under the conditions outlined in an- 
other paragraph, injections of small quantities of lukewarm 
water given for the purpose of dissolving fecal masses in the 
colon and cecum may be administered and an ileo-cecal tumor 
due to fecal accumulation may sometimes be caused to disappear 
thereby. 

In order to bestow complete rest upon the intestine the sov- 
ereign remedy is opium. Many surgeons object to its use in this 
disease as well as in intestinal occlusion (see page 430), on the 
ground that it obscures symptoms, causes valuable time to be lost, 
lulls the patient and the physician into a sense of false security. 
These objections are invalid if the temperature, the pulse, the 
leucocytes and changes in the tumor are carefully watched. The 
pain, it is true, is obscured, but, as indicated above, this symp- 
tom is the least important of all the signs of appendicitis and 
perityphlitis, the least constant and the least reliable index of 
the actual conditions existing. Under opium the local rigor of 
the abdominal muscles becomes much less intense, and palpation 
of the tumor or its recognition, as the disease progresses, much 
easier. This is very important from the standpoint of diagnosis 
and for the purpose of determining the exact time of an opera- 
tion, should surgical intervention become necessary. 

Unless one accepts the standpoint, therefore, that every case 
of appendicitis or perityphlitis should be treated surgically, opi- 
um is a most useful adjuvant to the treatment; for it effectu- 



ACUTE CIRCUMSCRIBED PERITONITIS — APPENDICITIS 477 

ally inhibits peristalsis and hence materially reduces the danger 

of perforation and extension of the process to larger areas of the Effect on pain; 

adjacent peritoneal coverings. Opium, too, if properly adminis- vomi tmg', nau- 

sea, tnirst 
tered, stops the vomiting and the nausea and by constipating the 

patient renders defecation unnecessary. These are all advan- 
tages inasmuch as they prevent periodical increase of the abdom- 
inal pressure and, above all, the necessity of the patient sitting 
up in order to vomit or to deposit the stools. Lastly opium aids 
in reducing the sensation of thirst, not to speak of its quieting 
effect on the patient's mind. 

The dosage should be regulated chiefly by the sensations of Dose 
the sufferer. Just enough and not more should be given to stop 
the pain and to keep the patient comfortable. When the pain 
disappears, opium should be discontinued, only to be adminis- 
tered again when the pain reappears. If no pain is present or 
if it is minimal, one can get along very well with very little opi- 
um. If there is no gastric irritation with nausea and vomiting, 
tincture of opium may be given by mouth in the dose of five to 
ten drops in a little water every two hours until the desired ef- 
fect is produced. If there is vomiting or nausea, opium is better 
given in suppository in two or three doses of one-half grain (0.1 
gm.) of the extract, or, finally, if neither method is well borne, 
opium may be given hypodermically in the following prepara- 
tion : 

Extracti opii liq. 1 

Water 20 

This amount may be injected two or three times a day. The 
solution should be freshly prepared and injected subcutaueously 
with particular aseptic precautions. Morphine, in the dose of 
a quarter to a half grain (0.015 to 0.03 gm.) may sometimes have 
to be given in place of opium, twice or three times a day, hypo- 
dermically. Opium, however, is far better than morphine, as it 
is much more effective in inhibiting intestinal peristalsis than 
morphine. Wherever feasible, opium in the form of the tincture 
or the extract should be given by mouth. 

The opium treatment should be continued for* about a week Duration of 
after the acute symptoms have disappeared. The constipation °pium treat- 
that results from the opium treatment is negligible, even if there 
are no bowel movements for six or seven days, especially as no 
food, leaving a residue, is eaten. Even if no opium is taken no Constipation 
attempt should be made to move the bowel by laxatives. When ne §' ll g lbl e 
the time has come for cleansing out the bowels gentle irrigation 
should be practised, but no purgatives should be administered. 



478 



ACUTE CIRCUMSCRIBED PERITONITIS APPENDICITIS 



Danger of 
purging 



Iiocal measures 
Ice bag 



Hot applica- 
tions 



Priessnitz 
compress 
Leiter coil 



Counter-irri- 
tants to be 
avoided 



Hydrotherapy 
to be avoided 



Formerly when the belief was prevalent that appendicitis 
was due to fecal accumulation (stercoral typhlitis) purging was 
generally resorted to throughout the course of the disease, and I 
have no doubt that much serious harm was done in that way. 
There is too great a tendency on the part of the patients and 
often the physician to insist on a bowel evacuation every day; 
and possibly one of the most difficult tasks that the practitioner 
is confronted with is to convince the patient and, above all, his 
friends, that no harm can arise from locking the bowels for a 
week if necessary in these cases, and I quote no less authority 
than Nothnagel in support of this view: "Even constipation 
lasting for a week is useful and does no harm. ' ' 

Of local measures the ice bag is the best in most cases. If 
the weight of even a small bag is disagreeable to the patient, the 
ice bag may be supported from a string, stretched from the 
head to the foot of the bed, so that the bag gently rests over the 
appendiceal region. One of the great advantages of this plan is 
that the patient must keep perfectly quiet in order to hold the ice 
bag in place. Some local treatment should, in every case, be in- 
stituted if for no other reason than to convince the patient that 
something active is being done for him, and the quieting psychic 
effect of an ice bag cannot be overestimated. Some patients feel 
better with a hot water bag or hot compresses, but I prefer cold 
throughout; at least, by all means, for the first five days. If 
cold is very disagreeable, and some patients, it will be found, 
complain bitterly of cold, cool Priessnitz compresses or a Leiter 
coil charged with cool water may be used instead. After the 
most acute symptoms of the disease are over, heat may be ap- 
plied in the form of hot poultices, a Leiter coil charged with hot 
water, large Priessnitz compresses or a Winternitz compress ( see 
index). It is very doubtful whether heat exercises any deter- 
minable effect on the absorption of perityphlitic exudates. 

Other local measures are of very little value. Counter-irri- 
tants, blistering, painting with iodine, leeching, etc., are best 
eschewed. They do no good in so far as affecting the process is 
concerned. Occasionally they relieve the pain somewhat, but 
this property need not be utilized when the opium treatment is 
being instituted. The chief disadvantage accruing from their 
use is that they injure the skin and hence render greater the 
possibilities of stitch abscesses, or even deeper pus infections in 
case an operation becomes necessary. 

Bathing or other hydrotherapeutic measures are distinctly 
harmful during the acute stage of the disease ; for, during the 
first few days, absolute rest is the prime requisite. A sponge 



ACUTE CIRCUMSCRIBED PERITONITIS — APPENDICITIS 479 

bath gently administered in bed, sponging each extremity sepa- 
rately with soap and tepid water for purposes of cleanliness, can 
do no harm, but even this is best omitted during the first few 
days. For reducing the temperature, cool sponging is never to 
be instituted in this disease, as no attempt should be made to re- 
duce or modify the temperature, because temperature fluctua- 
tions are one of our chief indices of the course of the disease and 
the advisability of operating. 

That massage of the appendiceal region should never be per- Massage to be 
formed during the acute stage need hardly be emphasized. Just cond e m ned 
what one might expect to accomplish thereby it is difficult to un- 
derstand. The proceeding is quite commonly followed, but must 
be condemned as immensely dangerous. During convalescence 
it is altogether superfluous and generally fraught with danger; 
for the fine peritoneal adhesions that act as a protective cover- 
ing over the inflamed area are very apt to be torn by manipula- 
tion from without. I do not believe that the absorption of large 
masses of exudate even later in the disease is in any way has- 
tened by abdominal massage. 

The after treatment of peritonitis and perityphlitis must con- After treat- 
cern itself chiefly with an attempt to prevent a recurrence of ment 
acute attacks. The diet should be regulated in such a way that Diet 
no irritating or indigestible foods are eaten. In order to prevent 
fecal stagnation in the cecum, bi-weekly high colonic flushings Colonic flush- 
and an occasional dose of castor oil may be given, although it is m £ s 
well known that free daily bowel movements by no means pre- 
vent the recurrence of appendicitis. Particular care should be 
taken not to indulge in violent exercise of any kind. The patient Avoidance of 
should lead a quiet life and should indulge in no out-door sports. 
Massage of the abdomen, as stated above, should be forbidden. 

Despite all these precautionary measures recurrences appear 
in a certain proportion of the cases, so that one must always 
think of the advisability of an operation for the removal of the The interval 
appendix after the first or subsequent attacks. opera ion 

Whereas an operation during the acute stage must always be 
considered an emergency measure and one that is never devoid 
of danger, the interval operation, which is becoming deservedly Advantages of 
popular, may be regarded as a conservative surgical inroad and atton^ ° P6r 
one of the safest operations. Moreover, it constitutes the most ef- 
fective and, in many cases, the only means of preventing the re- 
currence of attacks of appendicitis. Nevertheless, even this opera- 
tion should not be advised as a routine measure, for there is 
nothing more horrible to contemplate in the retrospect than the 
death of an apparently healthy individual from an anesthetic 
or from shock or from some unforseen complication that may 



480 



ACUTE CIRCUMSCRIBED PERITONITIS APPENDICITIS 



Objections 
against inter- 
val operation 



Indications for 
interim opera- 
tion 



Frequent re- 
currences 



Adhesions 



"Reflex" irrita- 
tion in neu- 
rotic or re- 
duced indi- 
viduals 



arise in the course of an operation in which the appendix is re- 
moved as a prophylactic measure. Besides, one can never pre- 
dict with absolute certainty that a second attack will occur; for 
only about twenty to twenty-five per cent, of all cases of acute 
appendicitis suffer a second attack. As a rule, and unless spe- 
cial reasons (see below) render it necessary to perform the in- 
terval operation after the first attack, I prefer to wait until a 
second attack has occurred and then, by all means, recommend 
removal of the appendix before a third relapse can supervene. 
This plan also generally appeals very strongly to the patient,, 
for most people will be very apt to imagine that they will con- 
stitute one of the lucky seventy-five to eighty per cent, of the 
cases who do not have a relapse and they will persist in this be- 
lief until the second attack convinces them that they belong to 
the unfortunate minority. 

Under the following circumstances, however, an interim oper- 
ation is advisable : 

First — When, as stated above, the patient shows a tendency 
to relapses at frequent intervals, immaterial whether the recur- 
rent attacks are light or severe; for the fact that new attacks 
supervene despite all care indicates that the local tendency to 
healing and the conditions for a restoration to a normal state 
are bad and that ablation of the diseased parts whose vitality,, 
i. e., resisting powers are, in most cases, materially reduced, is the 
only effective means of securing permanent relief. 

Second — When the existence of adhesions or of a tumor mass 
in the ileo-cecal region can be determined, which causes pain or 
signs of stenosis of the bowel lumen with constipation (see sec- 
tion on Intestinal Stenosis). Occasionally, it must be remem- 
bered, adhesions in the appendiceal region cause pain referred 
to other regions of the body, as the gall-bladder, the stomach, the 
urinary bladder, simulating diseases of these organs. In such 
cases, too, surgical treatment of the local conditions in the ileo- 
cecal region frequently brings relief from these symptoms. 

Third — If the diseased region about the appendix constitutes 
a source from which (more or less hypothetical) "reflex" irrita- 
tion emanates, sufficiently severe to cause functional gastric or 
intestinal disorders and derangements in or about remote organs. 
This event presumably occurs only in neurotic or reduced sub- 
jects; also in psychopathic individuals who have heard much of 
operation for appendicitis and the dangers of the disease if it 
is not operated upon. In such subjects a very pronounced con- 
dition of hypochondriasis is commonly engendered even by mild 
discomfort or pijiu in the appendiceal region. The mental suf- 
fering is very real and the conditions can often only be relieved 



CHRONIC PERITONITIS AND TUBERCULOSIS OF PERITONEUM 481 

by an operation. Such individuals, in fact, insist on an opera- 
tion themselves, present themselves to the surgeon rather than to 
the internist with the demand for surgical intervention and are 
quite satisfied, even if the appendix, as is very often the case, is 
found after removal to be in a normal or approximately normal 
condition. 

A discussion of the technique of surgical intervention and the 
indications for the different possible surgical measures that can 
be employed does not lie within the frame of this volume. 



CHRONIC PERITONITIS AND TUBERCULOSIS OF THE 
PERITONEUM. 

There are rare cases of chronic (exudative or indurative and Classification 
adhesive) peritonitis that are not due to tuberculosis, but most 
of the cases encountered are tuberculous in character. In addi- 
tion there is a carcinomatous form of chronic peritonitis that in 
its nature is hopeless and in which treatment is purely sympto- 
matic and must be directed against the pain, the ascites, etc. 

In the other varieties of chronic tuberculous and non-tubercu- spontaneous 
lous peritonitis, spontaneous recovery occasionally takes place, recovery 
Every effort should, therefore, be put forward by the physician 
to aid Nature in this endeavor by creating ideal surroundings internal treat- 
for the patient, insisting upon rest, the proper diet and hygiene ment 
and by symptomatically relieving distressing symptoms as they 
may arise. Surgery, too, occasionally aids in the treatment of surg-erv 
chronic peritonitis. Inasmuch as the treatment of the rare, non- 
tuberculous variety of chronic peritonitis does not differ materi- 
ally from that of the tuberculous, the latter alone may be dis- 
cussed. 

A patient suffering from chronic tuberculous peritonitis Rest and fresh 
should remain in bed completely at rest, preferably in the open 
air or in a thoroughly ventilated room. If it is at all possible 
the patient should be removed to a warm, sunny, equable climate. 
In the treatment of this disease the same rules, broadly speaking, 
should be inaugurated as in the management of any other form 
of tuberculous infection. These rules, as well as the limitations 
of the fresh air treatment and the contra-indication to its routine 
use have been fully described in the section on Pulmonary Tu- 
berculosis, and need not be repeated in this place. 

That the diet should be as nutritious and as non-irritating as Diet ] 

possible is manifest. The selection of the food will have to be 



482 CHRONIC PERITONITIS AND TUBERCULOSIS OF PERITONEUM 



External meas- 
ures 



Inunction 
with green 
soap 



Mercurial 
ointment 



Bandaging 
Compresses 



governed largely by the state of the digestive function and the 
amount of exudate present in the abdomen. Rectal feeding (see 
page 368) is, in many cases, a very useful means of supplying 
food values that cannot safely or with comfort be incorporated 
by mouth. 

It is somewhat difficult to render conservative judgment in 
regard to the efficacy of various external measures that are em- 
ployed in the treatment of tuberculous peritcfitritis ; for there is 
in this disease a marked tendency to fluctuations in the severity 
of the manifestations and to spontaneous recovery, so that the 
results obtained from various therapeutic measures are never 
free from ambiguity. 

As none of the measures to be presently enumerated can do 
any harm and as a larger proportion of cases seem to recover 
under their use than without them, they should be tried in every 
instance. 

A popular measure, adopted in nearly all large clinics, is 
inunction of the abdominal surfaces with potash soap (sapo kali- 
nus viridis). The soft soap is applied by stirring about a tea- 
spoonful with a little warm water to form a thin paste and rub- 
bing this into the skin of the abdomen. After about half an hour 
the soap is washed off with lukewarm water and the skin care- 
fully dried and powdered. This treatment is repeated every 
evening. As soon as irritation of the skin and eczematous erup- 
tions, etc., appear, the soap is no longer applied to the abdomen, 
at in the same manner to the skin in the lumbar region, the 
^cick or the buttocks, until the abdominal skin is healed, then it 
is reapplied to the abdomen. This treatment is often followed 
Dy rapid absorption of the peritoneal exudate. Generally, it is 
true, a thickened omentum or mesentery or massive adhesions 
remain behind. 

Instead of green soap, mercurial ointment may be applied in 
the same way, but it does not seem to be as efficacious in so many 
cases as soap, nor is inunction with this ointment, especially if 
continued for a long time, to be considered an altogether harm- 
less or indifferent procedure. 

In order to promote rest of the abdomen, light bandaging is 
useful. This practice also often affords considerable relief from 
pain ; it has no determinable effect on the absorption of the exu- 
date. Priessnitz compresses, hot fomentations or poultices may 
all be applied for producing symptomatic relief, but they cannot 
be credited with influencing the peritoneal process itself in any 
determinable way. 



CHRONIC PERITONITIS AND TUBERCULOSIS OF PERITONEUM 483 

Diuretics are commonly administered for the purpose of Diuretics 

draining off fluid from the peritoneal cavity. This practice is a 

rational adjuvant to the treatment, provided too much is not 

expected from increased diuresis. Any of the diuretic drugs 

mentioned in previous sections (see index) may be employed 

for this purpose. 

If rest, proper hygiene and diet combined with inunctions, Indications for 

sursrical inter- 
bandaging, the use of compresses and diuretics do not produce ven tion 

recovery within a reasonable time; if there is much pain, fever, 
diarrhea and no reduction of the ascites and, above all, if the 
patient continues to fail, to emaciate, then recourse must be had 
to surgery. It is a safe rule not to persist in non-surgical treat- 
ment for longer than two months, provided no improvement be- Time of opera- 
comes manifest during that time. If it should be found that tion 
the patient rapidly grows worse under internal measures, then 
a laparotomy should be done still sooner. 

The proper operation is incision and drainage of the perito- incision and 

neal cavity. Paracentesis with drainage or aspiration of the as- draina ge of the 

. -, . i , o , i peritoneal 

citic fluid, or simple puncture do not yield such favorable re- cavity 

suits. If the primary focus of infection can be discovered (espe- 
cially about the female genitalia, an intestinal ulcer, degenerated 
lymph. glands) it should be removed. And if the existence of 
such a focus and its location can be suspected or positively diag- 
nosed in advance, the laparotomy incision should, self-evidently, 
be made in the region of the abdomen where the diseased area 
is located. In cases of tuberculous peritonitis of obscure origin, Exploration of 
it is always good practice to explore the female sexual appara- female gen- 
tus after laparotomy; for the primary focus of the disease will 
often be found about these parts. Cases of tuberculous perito- 
nitis with and without exudate are amenable to treatment by lap- 
arotomy, although the results in the former variety are much 
better. 

There are no distinct contra-indications to the operation, pro- 
vided it is looked upon as a resort to be adopted only, as stated 
above, when internal measures have been tried in vain ; in other 
words, after conditions have been created and maintained for a 
sufficient length of time that might have favored a spontaneous 
cure, but failed to do so. 

A considerable proportion of the cases will be found, as al- p r0 o> nos i s un- 
ready indicated, to recover under expectant treatment. Of those de** internal 
that do not improve a certain number will die with as well as treatment*^ 
without an operation, and a certain proportion will recover after 
a laparotomy who would not have recovered without it. 



484 CHRONIC PERITONITIS AND TUBERCULOSIS OF PERITONEUM 

Contra-indica- Unless the patient, therefore, is in an advanced stage of gen- 

tions to sur- , , , ™ £ * . „ , 

gical inter- era l tuberculosis or suffers irom so serious a type of pulmonary 

vention or intestinal tuberculosis that it in itself renders the prognosis 

hopeless, the surgical treatment of chronic tuberculous perito- 
nitis should be given a trial in every case of the disease that does 
not yield to medical treatment. 



CHAPTER IX. 

DISEASES OF THE LIVER AND BILE 
PASSAGES 

CATARRHAL JAUNDICE. 

The treatment of catarrhal jaundice, especially in the begin- Treatment of 
ning of the disease, is essentially the same as the treatment of ^ al ca t a rrh 
the gastro-intestinal catarrh that produces the disorder. As the 
treatment of this catarrh has been discussed in full in previous 
sections, it need not be repeated here. 

As a rule the icterus does not develop until several days after 
the onset of the gastro-intestinal disorders (although in excep- 
tional cases it occasionally precedes them), so that, as a rule, 
cleaning out the stomach by lavage or by the use of an emetic is 
superfluous and the chief attention should be given to ridding 
the bowel of any irritating or poisonous material it may still 
incorporate. For this purpose a brisk purge, best of all, three Purgation by 
to five- grains (0.2 to 0.3 gm.) of calomel, or castor oil, followed 1^1°* salines " 
by a large dose of sodium phosphate or of magnesium sulphate colonic flush- 
and a colonic flushing, should be given at once upon the appear- ing 
ance of icteric symptoms. Such remedies as podophyllin, rhu- 
barb, jalap, convolvulin, scammony, gamboge and cathartic acid Purgatives not 
should not be used as purgatives in this condition, because they to be em P lo y ed 
seem to be practically inactive if bile is absent from the bowel. 

As soon as evidence of acute gastro-intestinal dyspepsia is Diet in the 
present, the patient should either refrain from food altogether or e § ,innm §' 
should be allowed to take only a little milk, some thin soup or 
strained gruel and water. During this period and until the Rest in bed 
tongue is clear, the fever normal and the epigastric or abdominal 
discomfort is gone, the patient is best kept in bed. 

With the disappearance or the mitigation of dyspeptic symp- Regime after 
toms, the diet should be made more liberal and the patient al- o^dvsnetrt^c 6 
lowed to get up a little each day. Some patients, in fact, are symptoms 
able without discomfort to attend to their daily work without 
displaying any other signs of illness than the yellow discolora- 
tion of the skin or sclera. Others, again, feel so ill throughout 
the course of the disease that they are forced to remain in bed 
for long periods of time. This occurs particularly in patients 
who develop, consecutively to the catarrhal swelling of the bile 
ducts, a condition of hepatic insufficiency (see page 488) with 
symptoms of profound self-intoxication. 



486 



CATARRHAL JAUNDICE 



Exclusion of 
fats 



Albuminous 
foods and car- 
bohydrates 



General char- 
acter of the 
diet 



Predigested 
foods 



Alkaline and 
alkaline-saline 
mineral 
waters 



Abundant 
water drinking 



During the whole period of bile duct occlusion or obstruc- 
tion the diet should be carefully regulated to take into considera- 
tion the absence of a normal amount of bile from the small intes- 
tine. 

Fats should be excluded from the diet, because their emul- 
sification and saponification, hence their absorption, is always- 
seriously interfered with, so that they travel through the intes- 
tine in an undigested form, undergo abnormal decomposition by 
intestinal bacteria, with the formation of poisonous and irritat- 
ing products and hence increase the catarrhal irritation that 
originally caused the trouble. Inasmuch, moreover, as in many 
cases of catarrhal icterus the pancreatic duct is in all probability 
also stenosed or occluded by catarrhal swelling (as manifested 
by the appearance of abundant undigested meat fibers, fat and 
starchy granules in the stools and sometimes glycosuria) fat is 
especially contra-indicated. 

The chief food, therefore, in catarrhal jaundice should be al- 
buminous material to which may be added easily digestible car- 
bohydrates, preferably dextrinized starchy foods and sugars. 
All food should be administered in an easily digestible form (see 
page 347), in the beginning, chiefly as liquid and semi-liquid arti- 
cles, namely broths, thin gruels, milk, buttermilk, meat jellies, 
gelatinous foods, very soft boiled or poached eggs; later finely 
chopped raw or rare beef, mutton, poultry, fish, a little zwieback, 
toast or crackers soaked in milk, gruels made of milk and rice or 
barley, arrowroot, tapioca, sago, etc. All foods containing coarse 
and indigestible particles, like skins and tendons, husks, seeds,, 
stems, pips, should be withheld for a long time. Alcoholic bever- 
ages are to be altogether forbidden. 

In case the pancreatic duct is occluded, too (see above), the 
digestion of albumens also suffers. In such cases the patients 
usually display a strong aversion for meat, and it should not be 
forced upon them. Here albumoses and peptones, various pre- 
digested foods, peptonized milk, etc., as well as certain of the 
easily digested vegetable albumens, can be utilized to advantage. 

Alkaline and alkaline-saline waters play an important part 
in the treatment of catarrhal jaundice. Their exact mode of ac- 
tion is not quite clear. It has been claimed that the alkalies they 
contain are excreted through the bile ducts and exercise a bene- 
ficial effect on the congested mucous lining of the bile channel. 
It is more probable that they favorably influence the catarrh in 
the small intestine and reduce the swelling around the bile duct 
orifice and hence aid in restoring patency of its lumen. The 
large amount of water that is ingested and absorbed might even 
be imagined to dilute the bile and hence render its outflow 



CATARRHAL JAUNDICE 487 

through the narrowed bile ducts easier. Whereas this effect of 
abundant water drinking is somewhat problematical, the limita- 
tion of water drinking certainly leads to thickening of the bile, an 
event that is to be energetically counteracted. Mineral waters 
at all events aid in dissolving some of the mucus accumulated in 
the bile ducts and hence act beneficially. Whatever the exact 
action of alkaline or alkaline-saline mineral waters, or of plain 
water, may be, clinically it may be considered established that 
the abundant ingestion of such waters, especially when they are 
taken warm and at frequent intervals, materially aids in restor- 
ing normal conditions in catarrhal jaundice. 

Intestinal irrigation with large quantities of water also exer- Intestinal irri- 
cises a useful effect, so that frequent enemata should be ordered § ' a 10ns 
in combination with copious water drinking. The injection daily 
by clysma of one or two quarts of cold water is a very popular 
and a very useful measure. The increased peristalsis of the in- 
testine combined presumably with increased contractions of the 
gall-duct musculature that is stimulated by such injections, aids 
in the expulsion of mucus and bile from the bile passages; more- 
over, the circulation in the whole portal system, and hence in the 
liver, is accelerated by such injections, while nervous reflex 
stimuli must also be imagined to travel to the liver from the 
lower bowel. All these factors aid in causing a decrease in the 
swelling of the bile-duct lining, in expelling the mucus and in 
re-establishing the flow of bile. 

Finally, the mechanical distention of the colon which is 
brought about by the injection of large quantities of water may 
exercise some traction on the region about the bile-duct orifices, 
and hence, too, stimulate contractions of the latter. 

Whereas all these explanations of the exact action of large, 
cool colonic flushings are more or less Irypothetical, clinical ex- 
perience, as in the case of copious water drinking, shows them to 
be actually useful. 

In order to stimulate the flow of bile towards the intestine cholagogues 
various cholagogue remedies were formerly employed. As a mat- 
ter of fact, however, only two drugs can be definitely credited 
with the power to stimulate an increased flow of bile, viz., prep- 
arations of salicylic acid and of bile acids. All the other so-called Salicylates 
cholagogue remedies act merely as purges and the appearance of Bile acids 
bile in the stools after their administration must be attributed 
to the abnormally rapid propulsion of the contents of the small 
intestine into the lower bowel, rather than to any stimulation of 
the bile flow. This subject will be referred to again in the Sec- 
tion on Cholelithiasis. In catarrhal icterus the use of cholagogue 
remedies is not indicated ; for the slight increase of the pressure 



488 



CHRONIC INFLAMMATION OF THE LIVER 



Bile 



Salol 



Itching 



Bathing and 
sponging 

Menthol 



within the bile-ducts that may be brought about by a stimula- 
tion of the flow of bile can hardly be considered effective in any 
way in overcoming the resistance offered to the outflow of bile by 
the catarrhal swelling of the bile-duct mucosa. Moreover, as 
soon as the back pressure within the bile-ducts reaches a certain, 
not very high, point, the manufacture of bile by the hepatic cells 
is automatically inhibited. Before this occurs stimulation of the 
bile flow will probably lead rather to increased diapedesis of bile 
constituents from the bile channels into the blood channels, which 
is detrimental, than to an exit of the bile into the bowel through 
" the stenosed bile-ducts. 

Bile and bile acids, however, serve a useful purpose in ca- 
tarrhal jaundice as well as in certain other forms of obstructive 
icterus, because by their administration a certain amount of bile 
is supplied to the small intestine and thereby intestinal digestion 
is aided, while at the same time a mild intestinal antisepsis is 
produced. Salol, too, answers the latter purpose. Both bile and 
bile acid and salicylic acid preparations, however, should be given 
in small doses only. 

Of symptoms complicating catarrhal icterus, intense itching 
often calls for relief. Here a variety of measures must often be 
tried before an efficient remedy is discovered, and it will gen- 
erally be found that the remedies that are helpful at first soon 
lose their power to relieve, so that frequent changes or alternation 
are generally required. Lukewarm baths, cold sponging, alcohol 
rubs, inunction of the skin with cocoa butter or lanolin all occa- 
sionally relieve. One of the best remedies is menthol applied in 
alcoholic solution in the strength of one to five, or in the form of 
a dusting powder in the proportion of one part of menthol to five 
parts of talcum, or as an ointment consisting of menthol, one 
part; sweet oil, two parts; lanolin, twenty-five parts. 



CHRONIC INFLAMMATION OF THE LIVER. 



(atrophic, hypertrophic cirrhosis, cardiac, biliary cirrhosis, 
syphilitic hepatitis, hepatic insufficiency.) 

Hepatic insufficiency is an important symptom complicating a 
great variety of hepatic disorders and leading in its ultimate 

♦Quoted in part from my article on Hepatic Insufficiency, Medical 
Record. 1906. 



CHRONIC INFLAMMATION OF THE LIVER 489 

consequences to complications about remote organs of the body. 
Its general pathogenetic significance and the means at our dis- 
posal for correcting hepatic insufficiency may therefore be treated 
of in this place, especially as a connected discussion of hepatic 
insufficiency will obviate the necessity of reviewing separately the 
treatment of the different organic lesions of the liver that pro- 
duce this symptom. 

Whenever an organ fails to perform its functions properly Hepatic msuf- 
we say that it is insufficient. This term may denote both quali- 
tative and quantitative variations from the normal. The more 
complicated and the more active the functions of an organ the 
more liable it is to insufficiency. The liver, therefore, possessing 
as it does the most manifold functions of any organ of the body, 
is particularly subject to functional derangements. Its exposed 
situation, moreover, and the peculiar arrangement of the four 
systems of capillaries that form an intricate labyrinth around 
and through each hepatic cell render the latter especially liable 
to injury by circulating toxins. These poisons reach the liver 
cells continuously from the general circulation in the hepatic 
artery, through the lymphatic circulation (especially from the 
peritoneum), the portal circulation and the bile channels. 

One may differentiate for clinical purposes between median- Causes 
ical, parasitic, and toxic causes of hepatic insufficiency, remem- 
bering always that the three may be and usually are, correlated 
and intimately connected. 

Chief among the mechanical causes are all sclerotic changes Mechanical 
causing overgrowth or contraction of interstitial liver tissues and causes 
thereby producing mechanical compression of liver cells or of 
their afferent blood-vessels. Then there is mechanical stenosis, 
occlusion or obliteration of large blood-vessels by embolism, 
thrombosis, or pressure from without, causing similar nutritional Cirrhosis 
changes, and, later, necrosis of large areas of liver cells. Again, Thrombosis 
the bile-ducts of the liver may become similarly narrowed or oc- 
cluded by biliary concretions or by the invasion of these chan- 
nels from without by parasites, in either instance producing stag- Bile duct oc 
nation of bile and mechanical compression of liver cells or of ary^cirrhosisS 
the blood-vessels that nourish them. Finally, certain heart lesions Heart lesions 
must be included among the mechanical causes, for, by producing (cardiac cirr- 
stasis of venous blood in the capillaries of the liver, they, too, 
exercise mechanical compression upon the hepatic cells and cause 
derangement of their function. 

As has been intimated, the parasitic causes of hepatic insuf- parasitic 
ficiency occupy an intermediary position between mechanical causes 
and toxic causes, for any micro-organism that invades the liver 



490 



CHRONIC INFLAMMATION OF THE LIVER 



Toxic causes 



General symp- 
tomatology 



channels or the liver tissues proper may act either as a foreign 
body by mechanically destroying liver cells by pressure or by 
occluding the blood- vessels or bile channels, or it may lead to the 
formation of chemical poisons that intoxicate the liver cells. 

The toxins, finally, that "-an produce hepatic insufficiency are 
so manifold that it would be useless to attempt to enumerate 
them in this place. It is sufficient to say that all the poisons gen- 
erated in the bowel, the spleen, or the pancreas must travel first 
to the liver before they can reach the general circulation beyond ; 
that all the manifold array of metabolic poisons that can be 
formed in the system at large always comes into particularly in- 
timate contact with the liver cells owing to the intricate inter- 
lacing of the capillaries of the hepatic artery and the hepatic 
lymph-channels in the liver. Finally, the liver, possessing as 
it does a most active metabolism of its own, continually manu- 
factures toxic intermediary bodies within its substance ; and this 
is particularly the case if its function is in any way deranged. 
The changes that the liver may undergo as a result of all 
these causes may vary from mild transitory functional derange- 
ments to destructive histological lesions of the hepatic cells. The 
symptoms of hepatic insufficiency are, therefore, very numerous. 
This is self-evident when we consider the many functions of the 
liver, any one of which may become qualitatively or quantitatively 
perverted. Our knowledge of the finer mechanism of the inter- 
mediary metabolism going on within the liver is, however, still 
so woefully incomplete that it is unfortunately well-nigh im- 
possible to interpret slight derangements of many of these func- 
tions correctly. For this reason we are as yet unable to recog- 
nize as early as we might wish the first manifestations of hepatic 
insufficiency, as we can, for instance, recognize early functional 
changes of the kidneys in the urine, or mild derangements of 
the stomach function in the gastric contents long before ana- 
tomical lesions supervene. From the standpoint of prophylaxis 
and therapy this is particularly deplorable. 

In order to understand the symptomatology of hepatic in- 
sufficiency and to treat it properly it is necessary to have a clear 
understanding of liver physiology, because it is manifestly im- 
possible to understand the pathology of any group of functions 
unless we understand their physiology; to appreciate or correct 
the abnormal until we understand the normal. 

The normal function of the liver may be summarized under 
the following five heads: (1) formation of urea; (2) conversion 
of sugar into glycogen and the storage of the latter; (3) forma- 
tion of bile; (4) elaboration both by anabolism and catabolism 



CHRONIC INFLAMMATION OF THE LIVER 491 

of circulating radicals of the fats and albumen ; (5) general dis- 
intoxication of circulating poisons and the formation of anti- 
toxic bodies. 

Perversion of these five mentioned functions must lead to the 
following results: 

(1) A diminution of the circulating urea and a flooding Decreased urea 
of the blood-stream with bodies that have failed to undergo con- 
version into urea in the liver, notably ammonia salts and ami do- 
acids, with the appearance of corresponding urinary symptoms — 

i. e., a decrease of the urinary urea and a corresponding increase 
of the urinary ammonia and amido-acids. At the same time, as 
urea is the most potent physiologic diuretic, a decrease in the 
amount of urine. 

(2) Owing to the inability of the liver to convert sugar into Interference 
glycogen and to store the latter, a flooding of the blood-stream / glycogen 
with an excess - of sugar that is derived from the ingested sugar 

or starches, with resulting hyperglycemia and glycosuria. This 
condition may be obscured if the patient does not happen to have 
eaten much starch or sweet foods, but it should readily appear 
even in mild degrees of hepatic insufficiency, as an alimentary 
glycosuria, if the patient is given appreciable quantities of starch 
or sugar in the food. 

(3) The inability of the liver to form bile leads to numerous Decreased bilo 
serious consequences that have already been indicated above. 

Chief among these is stasis of bile within the biliary channels and 
as a result diapedesis of poisonous bile constituents from the bile- 
capillaries into the blood-capillaries, in other words, icterus. In 
this connection a very important subject should be mentioned, 
viz., that jaundice occurs only in relatively mild degrees of 
hepatic insufficiency, whereas in very severe degrees jaundice cholemia 
cannot possibly occur, for the reason that the liver cells no longer 
form bile. Here the intoxication is especially severe because the 
products that should normally be disintoxicated by the liver and 
excreted into the bile pass through the liver cells unchanged and 
are returned to the circulation in a highly toxic form. This con- 
dition has been called by the French grande insuffisance hepa- 
tique. Another result of failure of the liver cells to produce a 
normal amount and the normal kind of bile is interference with 
the function of the upper portion of the intestinal tract. The 
withdrawal of the bile or the entrance of abnormal bile into the 
bowel allows intestinal fermentation to go on unchecked, fenders 
the normal emulsiflcation of fats impossible, and produces nu- 
merous other results that have been enumerated above. At all 
events the withdrawal of normal bile from the bowel in itself 



492 



CHRONIC INFLAMMATION OF THE LIVER 



Metabolic de- 
rangements 



Reduced disin- 

toxicating 

power 



Uremia 



General indica- 
tions for 
treatment 

Causal treat- 
ment 



causes an increased now of toxic bodies to pour into the liver 
through the portal vein and the intestinal lymphatics and hence 
promotes the causes that produce hepatic insufficiency. The de- 
rangement of the bile-forming function therefore produces a 
vicious circle that is highly dangerous. 

In the urine this condition usually becomes manifest by an 
increase of the aromatic sulphates, notably indican, and the ap- 
pearance of urobilin, bile pigments, and bile acids. 

(4) Failure of the liver to properly perform its share in the 
metabolism of the albumen and fats causes fragments of the lat- 
ter to be returned to the circulation, either unchanged or dis- 
assimilated into abnormal products. This, too, produces a gen- 
eral intoxication and may, in its ultimate consequences, lead to a 
syndrome that is not distinguishable from uremia, and that is, 
moreover, in all probability uremia (see page 237). Here the 
urine contains abundant ammonia salts, relatively small quan- 
tities of urea and usually an abnormal amount of fatty acids, 
possibly of leucin and tyrosin. 

(5) The loss or reduction of the normal disintoxicating power 
of the liver finally is the most serious result of hepatic insuffi- 
ciency and usually constitutes a terminal stage of the affection. 
Here the portals are thrown wide open to the invasion of the 
body with poisons of a thousand kinds that are formed in the 
bowel and in the tissues at large. That the organism cannot 
long withstand this toxic flood is self-evident. In such cases the 
toxicity of the urine will be found to be enormously increased, 
while, at the same time, the kidneys invariably became affected, 
for upon them is now thrown the task of ridding the body of cir- 
culating poisons, a function that normally they share with the 
liver. When renal insufficiency complicates hepatic insufficiency 
a severe toxemia must develop in very short order, and again a 
fulminating syndrone is presented that closely'simulates uremia. 

The treatment of hepatic insufficiency may be considered 
under two headings: (1) The suppression of its causes. (2) The 
symptomatic treatment of its manifestations. 

Causal treatment is in most instances synonymous with pro- 
phylaxis. Three factors, as I have mentioned above, chiefly deter- 
mine insufficiency of the liver cells, i. e., infection, intoxication, 
mechanical causes. 

The latter, unless we are dealing with some lesion that me- 
chanically compresses the common duct and that can be removed 
surgically, is not amenable to treatment, so that in this instance 
we are limited to symptomatic therapy. There is an exception 
to this rule, that is, syphilis. Here we may be dealing with a 



CHRONIC INFLAMMATION OF THE LIVER 493 

gumma located in such a way that it produces compression of a Antiluetic 
large bile duct or of an important blood-vessel, or there may be g^^^tfc "* 
a syphilitic interstitial hepatitis. In both of these instances anti- Hepatitis 
syphilitic treatment may remove the cause, mechanical though 
it be. To an extent this also applies to what may be called me- 
chanical hepatic insufficiency due to venous stasis in the liver 
following heart lesions. Here cardio-tonic treatment may cause 
the symptoms of hepatic insufficiency to disappear. 

In the case of the intoxicating factors the source of poison 
is in the overwhelming majority of cases the gastro-intestinal Intestinal anti- 
tract. Here causal treatment should be carried out according to se P sls 
the following principles : To regulate the diet in such a way as 
to limit the ingestion of substances that are in themselves poison- 
ous or that undergo changes in the bowel that lead to the forma- 
tion of poisonous bodies; to reduce to the lowest possible min- 
imum intestinal putrefaction; to prevent as far as possible the 
absorption of whatever poisonous bodies may have gained en- 
trance to the bowel or may have been formed there; to promote 
the destruction of the latter in case they enter the circulation, 
and, above all, to hasten the rapid elimination of circulating 
toxins. The latter indication prevails with equal force in the 
case of poisons that are not formed within the bowel, but that are 
generated within the tissues of the body (endogenous poisons), 
as in infectious diseases and in a variety of metabolic disorders. 

Under the head of causal treatment all those measures might stimulation of 
also be included that we know are capable of stimulating the hepatic cells 
hepatic cells to renewed activity when their energies begin to 
flag, but this treatment must be carried out with conservatism, 
as I will have occasion to show further on. 

Symptomatic treatment includes the treatment of the protean Symptomatic 
array of sequelae of hepatic insufficiency. As derangement of treatment 
the liver function in its ultimate consequences may lead to the 
greatest variety of psychic, nervous, cardio-vascular, renal and 
metabolic disorders, symptomatic treatment of hepatic insuffi- 
ciency, as stated above, in the broader sense covers a large field 
of therapy. 

Probably the most important dietetic rule in the treatment Dietetic treat- 
of hepatic insufficiency is a negative one, i. e., that all alcoholic ment 
beverages should be rigidly excluded from the diet. We do not 
realize sufficiently that pure alcohol is the least toxic of the alco- 
hols that are used in the food of man; the higher alcohols and 
certain aldehydes and essential oils that are found in cheap 
liquors and that bestow the aroma or bouquet upon the various 
wines, liqueurs, and cordials, are much more poisonous even in 



494 



CHRONIC INFLAMMATION OF THE LIVER 



Spices and 
condiments 



Reduction of 
fats 



Meat and eggs 



Carbohydrates 



Vegetables 



Milk 



General ar- 
rangement of 
the diet 



the small quantities in which they are used ; thus, e. g., absinthe 
contains some eleven different principles, all of which are poi- 
sonous. Alcohol itself, therefore, unless taken in enormous quan- 
tities, is not so terribly dangerous ; but no one drinks pure dilute 
alcohol, but rather alcoholic beverages of various kinds, and as 
the latter are poisonous on account of the impurities they con- 
tain, it should be a cardinal rule in the treatment of hepatic in- 
sufficiency to exclude them rigidly from the diet. 

On the same grounds spices and condiments should always be 
excluded because they contain essences and alkaloids that are 
toxic to the liver. 

A second cardinal rule is to limit the ingestion of fats, for 
they are very poorly digested owing to the deficiency of bile acids 
from the bowel ; it is clear that in this case, as stated above, they 
are not properly saponified and emulsified, undergo rapid decom- 
position in the bowel, and in this way lead to the formation of 
acid and acrid products that are highly irritating to the liver 
and the bowel. It has been shown that in cases of hepatic insuffi- 
ciency the urinary toxicity increases greatly when much fat is 
given. "While it is not necessary, therefore, to exclude the fats 
altogether from the diet, they should be reduced to a minimum. 

Meat and eggs should also be reduced, for they furnish the 
bulk of the most toxic intestinal products whenever intestinal 
putrefaction goes on unchecked, and this we know to be the case 
when the bile is deficient or its composition is changed. 

There remain, therefore, as chief articles of food, vegetables 
and carbohydrates; the latter, in particular, are not toxic nor 
do they lead to the formation of toxic bodies in the bowel; and 
besides, sugar, as we know, stimulates the liver functions to ac- 
tivity. Of course, care should always be exercised not to admin- 
ister a diet containing too large a proportion of carbohydrate food, 
for otherwise fermentative dyspepsia, constipation, and a variety 
of digestive disorders may supervene. One should simply in- 
crease the amount of carbohydrate food to replace the deficit of 
fat. Milk can always be given with impunity. An exclusive milk 
diet, however, is for many reasons objectionable. (See page 208.) 

To summarize, the patient should be placed upon a bland 
mixed diet, containing no alcoholic beverages, a minimum of fat, 
a small amount of albuminous food, and plenty of fresh fruits, 
vegetables, milk, cereals, starches, and, with care, sweets. That 
the details of this diet should be regulated in such a way as to 
consider the individual idiosyncrasies and tastes, and above all 
complications in other organs, notably the kidneys, need hardly 
b° emphasized. 



CHRONIC INFLAMMATION OF THE LIVER 495 

In view of the fact that the chief source of the poisons that 
intoxicate the liver and produce hepatic insufficiency is the in- 
testinal tract, it is of paramount importance to attempt intestinal 
antisepsis (see index) in every case of hepatic insufficiency 
that comes under observation. 

That the absorption of bowel poisons after they have once Evacuants 
formed can be restricted by the use of evacuants is clear. A 
saline laxative given at frequent intervals, combined possibly 
with enemas to clean out the lower bowel, is a useful measure. 
Purgatives or drastics that can irritate the liver should be used 
cautiously. 

All attempts that have so far been made to promote the de- 
struction of poisons after they have once been absorbed have been Oxidizing- 
abortive. A. Kobin, as is well known, introduced a so-called reatni8n 
oxidizing treatment and advised the inhalation of oxygen, the 
use of iron and manganese preparations. I have never seen any 
tangible good results follow this treatment. Cold hydrothera- Cold hydro- 
peutic measures, thanks to the leucocytosis, the increased meta- era Py 
bolism, and the better circulation of lymph they produce, are of 
much use. 

The elimination of absorbed poisons by the various emuncto- 
ries of the body is always indicated. Here elimination by ca- 
tharsis (see above) and diaphoresis, preferably brought about Diaphoresis 
by hydriatic measures, has a useful place. To attempt elimina- and catharsis 
tion by forced diuresis is, however, dangerous, as the toxins that 
are forced through the kidneys are bound to irritate them, and 
injury to the kidneys should of all things be avoided. 

The last and most important task is to attempt to restore the To restore 
function of the destroyed hepatic cells. Here the same principles * unc t 1 . on °* 
must obtain as in the treatment of any organ that has become 
fatigued. In very mild cases slight stimulation may at once 
restore normal tone; in more chronic conditions, however, rest 
is the prime requisite, for when the affected organ is spared 
nature soon re-establishes functional equilibrium. "We follow this 
plan exclusively in diseases of the stomach by withdrawing food 
for a while or by reducing the daily ration. We do it in dis- 
eases of the nervous system when we give a rest cure. We do it Rest 
in diseases of the heart when we put the patient on a mild, non- 
irritating diet with an ice bag over the heart. We are beginning 
to apply the same plan in diseases of the kidneys, and it cer- 
tainly has a grateful field of application in the case of the liver. 

Following a period of rest, what might be termed gentle ex- Exercise 
ercise of the organ may be instituted either by throwing upon 
the liver tasks that it should normally be able to fulfill, or by 



496 



CHRONIC INFLAMMATION OF THE LIVER 



Danger of ac- 
tive stimula- 
tion of the 
liver 



Hydrotherapy 



Cholagogues 



Alkalies 
Antipyrin 



Urea 



Organotherapy 
Liver extracts 



gently stimulating it with remedies or physical measures that 
we know can produce this purpose. Active stimulation with 
powerful remedies should be reserved as an emergency measure- 
in extreme cases, for nothing will so rapidly produce complete 
functional inadequacy of an organ that is functionally impaired 
as over-stimulation in the beginning. 

For the purpose of stimulating the function of the liver we- 
can have recourse in the first place to certain hydrotherapeutie 
measures. It has been established by careful studies that general 
hot baths or the brief application of cold locally over the liver,, 
preferably in the form of a stream of cold water directed for a 
minute or two against the hepatic region, will energetically stim- 
ulate the flow of bile. The same result can be obtained by the 
application of a so-called Priessnitz compress over the liver 
region. A towel is wrung out of cold water and laid over the 
liver and covered with a flannel. 

Many remedies are said to stimulate the formation of bile. 
Unfortunately, most so-called cholagogues do not possess this- 
power at all, but simply irritate the stomach, the intestine, and 
the liver. Best of all are the salicylic preparations and the bile- 
acids. (See page 488.) Preference should be given to the lat- 
ter remedy because the salicylates are somewhat irritating to the 
kidneys. The stimulation of the glycogenic function of the liver 
can be brought about by an active alkali therapy. Antipyrin/ 
too, possesses this power. Best of all, however, are the starchy 
and sweet foods, and these are already properly included in 
the diet. 

We know of no remedy that can stimulate the urea-forming 
function of the liver. The administration of abundant al- 
buminous food constitutes a physiological stimulant to this func- 
tion, and, if sufficient care is exercised that the bowel is kept 
aseptic, there is no reason why enough of albumen should not 
be given for this purpose, only however in mild stages of the dis- 
ease. Some writers have advised the use of urea, itself, claiming 
that a certain amount of urea is necessary, especially in order 
to promote diuresis, and that where its formation is deficient it 
should be supplied. This plan does not appeal to me, and, de- 
spite the various favorable reports on this therapy I have never 
been able to convince myself of its value. 

Liver extracts given in the form of powdered calf's liver or 
pork liver, suspended in milk or water, by enemata, or even sub- 
cutaneously, is worthy of trial. Symptomatically I have seen 
some good results from the ingestion of liver extract in cases; 
of cirrhosis of the liver with hepatic insufficiency, especially in 



CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS 497 

the direction of an increased urea excretion, an increased toler- 
ance for carbohydrates, and an apparent improvement in some 
of the nervous manifestations. That the administration of liver 
extract stimulates the regeneration of liver cells, as is claimed by 
some clinicians (Gilbert andCarnot) ; that it produces a vicarious 
hypertrophy of those portions of the liver that are not affected 
is hard to prove. 

Finally, something* may be said in regard to the danger of Dangers of op- 
operative interference in cases of hepatic insufficiency. There f erence an a " 
is in most of these cases a tendency to hemorrhage due, possibly, chloroform 
to the circulation in excess of bile acids; for the latter have 
a distinct hemolytic power and interfere with the coagubility of 
the blood. Besides, the administration of chloroform is a very 
dangerous procedure in any case, even of mild hepatic insuffi- 
ciency, for, in predisposed subjects who, we must assume, possess 
an idiosyncrasy against chloroform, a condition may develop 
which closely simulates acute yellow atrophy of the liver, both 
clinically and anatomically. I think it is just as important 
for this reason that surgeons should, as far as possible, examine 
the functional state of the liver before an operation as they do, 
or should, study the condition of the kidneys. If any of the evi- 
dences of hepatic insufficiency that have been enumerated above 
should be present, then chloroform at all events should not be 
administered as an anesthetic, and the possibility of profuse 
capillary hemorrhages be remembered. If it were not for this 
difficulty of operating upon cases of hepatic insufficiency the so- 
called Talma operation, which consists in producing an artificial Talma opera- 
collateral path for the flow of blood from the portal circulation tlon 
into the systemic circulation, either by epipoplexy or by curet- 
ting the parietal peritoneum and the omentum, would be more 
useful than it really is. 

Treatment of the dyspeptic symptoms, the ascites, the hem- symptomatic 
orrhages, the cardio-vascular changes, the nervous manifesta- treatment 
tions, the nephritic lesions, and the icterus that accompany or fol- 
low chronic inflammations of the liver need not be discussed 
again in this place, the different measures to be employed having 
been fully presented in appropriate sections. 



CHOLELITHIASIS, CHOLANGITIS AND CHOLECYS- 
TITIS. 

In simple uncomplicated cholelithiasis, i. e., in a subject show- Prophylactic 
ing a tendency to recurrent attacks of gall stone colic, prophy- treatment 
lactic treatment directed towards promoting an active flow of 



498 CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS 



Stimulation of 
the bile flow 



Diet 



Albumens 



Carbohydrates 



Pats 



Alcohol 



Small meals at 
frequent inter- 
vals 



Abundant 
water drinking 



Mineral waters 



bile, and towards hindering catarrhal inflammation of the gall- 
ducts and the gall-bladder, can be instituted. 

Every endeavor should be put forward to promote a steady 
flow of bile towards the intestine ; for, in this way stasis of bile 
constituents is prevented. This is an important element in 
prophylaxis, inasmuch as stagnating bile forms a suitable nidus 
for the development of bacteria. Besides the invasion of the 
bile ducts and gall-bladder by bacteria from the intestine is ren- 
dered quite difficult if the bowel passages are constantly drained 
by an active stream of bile flowing towards the intestine. 

In order to stimulate the current of bile the diet should be 
mixed. It should contain an abundant quantity of albumen 
and relatively small quantities of carbohydrates and fats. Al- 
bumens more than starchy, sweet and fat foods lead to the for- 
mation of abundant bile acids and the latter render the bile more 
fluid, more abundant and also impart to it certain antiseptic 
properties. Carbohydrate foods, on account of their tendency to 
produce congestion of the liver and intestinal fermentation, 
when given in abundant quantities, should be somewhat reduced 
in quantity. Fats are apt to irritate the bowel and to produce in- 
testinal dyspepsia, hence they should be very much reduced or 
altogether excluded from the diet, especially as their presence 
in the bowel would be particularly detrimental should an attack 
of gall stone colic with gall-duct occlusion suddenly supervene. 
Alcoholic beverages, spices, condiments and all irritating or 
coarse foods that can determine catarrhal conditions of the upper 
digestive tract should be avoided. 

A steady flow of bile, moreover, is stimulated by the admin- 
istration of meals at frequent intervals. Consequently in addition 
to the three regular main meals a day a patient with cholelithi- 
asis should be instructed to take a glass of milk or an egg-nog 
with a few crackers, or a piece of toast, in the middle of the fore- 
noon and the middle of the afternoon. The administration of a 
similar meal in the middle of the night is rarely necessary. 

Plenty of water, especially some of the alkaline or alkaline- 
saline mineral waters, should be taken; the latter in particular 
aid in dissolving the mucus in the bile passages and hence in 
maintaining the bile ducts open. It is questionable whether 
alkaline waters exercise any determinable effect upon the alka- 
linity of the bile and hence, as some clinicians claim, aid in keep- 
ing the ingredients that precipitate in the form of concretions in 
solution. So much is certain that they exercise no solvent action 
upon gall stones after the latter have once formed. The chola- 
gogue action of mineral waters is also in doubt and the dilution 
of the bile that is postulated from the administration of abundant 



CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS 499 

liquids is problematical. Too great restriction of the intake, how- 
ler, assuredly leads to greater viscidity of the bile, hence favors 
sluggishness of the bile stream and stagnation. The chief action 
of alkaline mineral waters is presumably exercised in preventing 
^astro-intestinal catarrh, hence abnormal fermentation, the devel- 
opment of bacteria and catarrhal swelling about the orifices of 
the gall-ducts. The laxative properties, finally, of certain min- 
eral waters stimulate intestinal peristalsis and indirectly also 
peristalsis in the bile ducts; in this way, then, they also aid in 
the expulsion of the bile. 

The great benefits accruing from the use of certain mineral Eesort treat- 
waters taken in resorts must be attributed only in part to the m e n t 
abundant ingestion of the liquid and the incorporation of the 
alkaline and saline principles they contain. The life in a resort, 
itself, the respite from the daily routine, the out-door existence, 
the careful regulation of the general regime and of the exercise, 
the scientific employment of hydr other apeutic measures and the 
management of the case by skilled specialists are all elements 
that contribute towards the good results obtained from the resort 
treatment of cholelithiasis. 

The regulation of exercise and abdominal massage are all _ . , 

° ° Exercise and 

useful adjuvants to the treatment, chiefly on account of their massage 

power to stimulate the flow of bile. Violent exercise should never 
be permitted to patients showing a tendency to gall stone colic ; 
for sudden movements of the body are very apt to cause im- 
paction of a gall stone and to precipitate an attack of colic. Vio- 
lent exercise is altogether contra-indicated in cases of cholelithi- 
asis complicated with cholecystitis and cholangitis, or in patients 
with chronic icterus due to impaction of a gall stone ; for in these 
cases there is always danger of perforation and resulting peri- 
tonitis. 

The clothing should be loose and all pressure by the cloth- 
ing on the liver region avoided. In women tight skirt bands and ° ins 
corsets should be forbidden and the clothing suspended from the 
shoulders. In men the wearing of belts is to be forbidden. It 
is usually a good plan to order these patients to loosen the cloth- 
ing about the waist after meals. 

The use of cholagogues is indicated as a prophylactic measure 
in cases of cholelithiasis. As stated above in the Section on ° a ^°^ ues 
Catarrhal Jaundice, only two remedies can directly be credited ' 
with bile-stimulatiniz' properties, namely, the bile acids and the 
salicylates. In addition to their cholagogue powers, these two 
remedies als^ possess antiseptic properties that are especially use- 
ful in cholelithiasis; for both these remedies after absorption 



500 



CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS 



Sodium glyco- 
cholate 



Salicylic acid 



Expulsion of 
gall stones 



Olive oil 



Enteroliths 
after oil 



from the bowel are re-excreted in part via the gall-ducts, hence 
they promote an increased outpouring of bile that has been ren- 
dered, to some degree at least, antiseptic. 

The best way to administer bile acids is in the form of sodium 
glycocholate in doses of one-half to two grains (0.03 to 0.13 
gm.). Salicylic acid is better than the salicylates and a pill 
containing a grain each of sodium glycocholate and of salicylic 
acid, given three or four times a day, must be considered an 
efficient means to stimulate the flow of bile. All the other rem- 
edies that have been recommended at different times as chola- 
gogues act presumably chiefly as laxatives. They may exercise 
some effect upon the flow of bile by increasing intestinal peri- 
stalsis and indirectly the peristalsis of the gall-ducts. They are 
vastly inferior, however, in efficacy to the two above-mentioned 
remedies (see also Section on Catarrhal Jaundice). 

All the measures enumerated not only aid in preventing the 
formation of gall stones, but also assist in the expulsion of gall 
stones that may be present in the bile ducts. In addition certain 
other remedies may be used for the latter purpose, namely, olive 
oil and glycerin. 

The former is warmly recommended by some clinicians and 
condemned as utterly useless by others. Personally, I have never 
been convinced that the use of olive oil materially influences the 
course of a case of cholelithiasis, prevents the formation of gall 
stones, or aids in their expulsion. It is very questionable, in 
fact, whether the oil after absorption really enters the bile ducts 
and is re-excreted with the bile. Whatever good effects may oc- 
casionally be observed from the use of olive oil must be attributed 
in great part, at least, to its slightly nauseating and laxative 
properties whereby it stimulates peristalsis and contraction of 
the bile ducts. After the administration of olive oil small masses 
of saponified oleic acid are frequently deposited with the feces, 
and it is quite probable that these enteroliths have occasionally 
been taken for expelled gall stones. 

Olive oil may either be given in one or two tablespoonful 
doses in the evening before retiring, or, better still, in fifteen 
drop doses before breakfast on an empty stomach, every day or 
every other day. A convenient formula for the administration 
of olive oil is the following, recommended by Rosenberg: * 



R 



Olive oil 

Brandy 

Menthol 

The yolk of one egg 



200.0 

20.0 

0.2 



CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS 501 

This mass is thoroughly mixed and taken in two doses an hour 
apart. The disagreeable fatty taste of the oil can be removed by 
eating little pieces of orange or lemon peel, or taking a teaspoon- 
f ul of orange or lemon syrup. 

Glycerin, which is sometimes a very effective remedy in renal Glycerin 
lithiasis (see page 231), is hot so useful in cholelithiasis. It 
should be given in the dose of about half a teaspoonful in some 
mineral water once a day. Glycerin, too, probably acts on ac- 
count of its laxative properties. 

The attempt to promote solution of gall stones in the biliary The solution of 
passages by the administration of any medicine by mouth must 8& 
be considered altogether futile. Various drugs, like olive oil, 
ether, turpentine, chloroform, sodium oleate (eunatrol), and 
many others that are credited with this power are, I think, alto- 
gether inert in this direction. 

If large masses of gall stones are present and if their re- Surgical re- 
moval becomes desirable (see below), then surgical means should SJInes 
be promptly adopted and no time wasted with medicinal meas- 
ures. 

In view of the tendency nowadays to operate somewhat pro- Warning 
miscuously in every case of gall stone disease, a certain warning miscuous sur- 
may be uttered. There are distinct indications for surgical in- gical treatment 
tervention which will be presently discussed. The appearance disease 
of gall stone symptoms, or even of signs of gall-bladder or bile 
channel infection, must not, however, be considered the signal 
for an operation in every case. A large proportion of patients 
suffering from chronic cholelithiasis recover without surgery, 
and it is well worth while in each case to give the patients the 
full benefit of medical treatment. 

Surgery at best can only remove gall stones or promote drain- Limitations of 
age of the gall ducts or gall bladder, but it cannot affect the sur £ er y 
morbid processes that originally led to the formation of gall 
stones or infection of the bile passages. The treatment of the 
case, moreover, is by no means completed after the gall stones 
have been removed, or the gall-bladder or the gall passages have 
been drained; and a patient once afflicted with gall stones, even 
after he has been operated upon, should remain under careful 
supervision until the hepatic disorder and the catarrhal condi- 
tion of the bile passages are completely cured. This aim can 
only be accomplished by medical means, namely, by careful reg- 
ulation of the patient's diet and general mode of life, by the ad- 
ministration of proper remedies and the institution of the other 
measures that have just been enumerated. 

Under the following conditions surgical intervention, how- Indications for 
ever, becomes necessary and constitutes the only effective means tervention 1 " 
of treating these cases, namely: 



502 



CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS 



Recurrent at- 
tacks of colic 
Suppurative 
cholangitis and 
cholecystitis 



Complete gall 
duct occlusion 



Peritonitic 
signs 



Adhesions 



First. In frequently recurring attacks of gall stone colic 
that do not yield to internal treatment, that reduce the patient's 
health and impair his working capacity, especially if the pres- 
ence of many gall stones in the gall bladder can be determined. 

While one can never predict that an attack of gall stone colie 
may not be the last one, it is, nevertheless, important to remem- 
ber that each attack injures the bile passages and may lead to 
ulceration or the formation of dangerous strictures or adhesions 
or stenosis (or acute, hemorrhagic pancreatitis). Repeated at- 
tacks, therefore, in which any evidence of such complications ap- 
pears, must be considered fit for surgical intervention. 

Second. If suppurative cholangitis or cholecystitis compli- 
cates the disease. Here spontaneous recovery may occur (see 
below), but free drainage and irrigation and removal of the gall 
stones that keep up the irritation of the gall-bladder and bile 
passages, is usually the quickest and most certain means of pro- 
ducing a cure. 

Third. In complete common duct occlusion which persists 
and leads to the development of profound icterus. This condi- 
tion should never be allowed to persist for longer than two 
months at most. If, during this time, serious impairment of the 
patient's health occurs, an operation should be performed much 
sooner. It is usually dangerous to wait too long in this condi- 
tion, because in chronic icterus of this kind a tendency to hem- 
orrhage develops which may render an operation especially dan- 
gerous. 

Fourth. Peritonitic symptoms developing as the result of 
perforation or rupture of the gall-bladder or its ducts, occurring 
either during an attack of gall stone colic or developing slowly 
in the course of chronic stenosis or ulceration of the gall-bladder 
or the bile duct. 

Fifth. Adhesions forming around the gall-bladder and pro- 
ducing mechanical dislocation or stenosis of adjacent organs, es- 
pecially the stomach, the duodenum and the colon, and causing 
a variety of distressing symptoms, chiefly pain, gastro-intestinal 
disorders, and biliary colic. While it is true that adhesions are 
apt to form again even after an operation, a skillful operator 
can usually manage the field of operation in such a way that the 
new adhesions form in a more favorable locality. 



Treatment of 
the acute at- 
tack 



TREATMENT OF THE ACUTE ATTACK. 

In treating an acute attack of gall stone colic the following- 
indications must be met : — 

First, to stop the excruciating pain. 



CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS 503 

Second, to facilitate the passage of the stone and prevent its 
permanent impaction. 

Both of these indications are best met by opiates; for the Opiates 
latter not only promptly stop the pain, but also cause the relaxa- 
tion of the muscularis lining the gall-ducts and hence facilitate 
the passage of the stone. One must imagine that spastic reflex 
contractions of certain portions of the bile duct are stimulated 
by the stone and that, in this way, the concretion is held tightly 
in one place. If opium or morphine are given, this tonic con- 
traction stops and new peristaltic movements are gradually re- 
sumed until the stone is either expelled or is again arrested by 
spastic contractions of some part of the bile passages farther 
down; as soon as this occurs an opiate should again be admin- 
istered. 

The best way to administer opiates is, therefore, to give a Dose and ad- 
hypodermic injection of a quarter of a grain (0.005 gm.) of mor- ministration 
phine as soon as the patient is seen and to repeat the dose once 
or twice according to the requirements of the case; or a hypo- 
dermic of morphine may be given at first and later, when 
attacks of colic return, ten to twenty drops of the tincture of 
opium by mouth, to be repeated at intervals of one or two hours. 

Belladonna and atropine also relieve the muscle spasm and Belladonna and 
can be used instead of, or together with, opium or morphine. atro P me 
Belladonna is best given either as the extract of the leaves in 
powder form in the dose of y± to V2 grain (0.015 to 0.03 gm.) ; 
or in the dose of five to fifteen minims (0.3 to 1 cc.) of the tinc- 
ture of belladonna leaves repeated several times; or as atropine 
sulphate, in the dose of one-hundredth to one two-hundredth of a 
grain (% to 1 mg\), either alone or in combination with a quar- 
ter of a grain (0.015 gm.) of morphine. 

Other remedies employed for the purpose of stopping the Antipyrin and 
pain in cholelithiasis are antipyrin and other members of the otlier anal- 

g GSXCS 

group of coal tar analgesics, sodium salicylate and many more, god-rim sa i- 
No remedy, however, is as efficacious as opium or belladonna, icylate 
If the pain is very severe and does not yield promptly to the ad- 
ministration of morphine, then a few drops of chloroform on ice, 
or a teaspoonful of chloroform water, repeated at frequent inter- Chloroform 
vals, or even a few whiffs of chloroform, may have to be given. 
Chloral is not as valuable as chloroform and is, in most cases, Chloral 
a dangerous remedy to be employed. 

Heat or cold may be applied locally. Heat is usually much Hot and cold 
more effective in alleviating the pain, especially when applied a PP llcatio,x « 
continuously by means of hot poultices, a Leiter coil charged 
with hot water or a thermophore (see index). Immersion of Hot batn ; 



504 



CHOLELITHIASIS. CHOLANGITIS AND CHOLECYSTITIS 



Cold applica- 
tions 



Laxatives 

Enemata 



Collapse 



Analeptics 

Alcoholic 
drinks 



Cholangitis 
and cholecys- 
titis 



Cholagogue- 

antiseptic 

treatment 



the patient in a hot bath is also a very effective means, in most 
cases, of cutting the attack short. 

If heat is not well borne, and this is most apt to be the case, 
especially in the presence of complicating cholecystitis and 
cholangitis, cold may be used instead. As pressure upon the 
gall-bladder region is rarely well tolerated, it is best to suspend 
the ice bag over the patient and to have it barely in contact with 
the gall-bladder region, or to use a Leiter coil charged with ice 
cold water applied to the same place. 

Free evacuation of the bowels by the use of laxatives and 
enemata should always be promoted when an attack of gall stone 
colic occurs. If castor oil or sodium phosphate are vomited, then 
high rectal injections of cool water may be administered both 
for the purpose of cleaning out the lower bowel and for the pur- 
pose of stimulating intestinal peristalsis (see the Section on Ca- 
tarrhal Icterus, page 487). Enemata of olive oil are also useful. 

If very reduced and weak patients should develop symptoms 
of collapse or shock from the severe pain, analeptics (see page 
32) may have to be administered, especially if the pain is not 
promptly controlled by the use of morphine. A little champagne, 
hot alcoholic drinks, camphor, ether, ammonia, or adrenalin chlo- 
ride administered by mouth or hypodermically are all of use. 

CHOLANGITIS AND CHOLECYSTITIS. 

In infections of the bile ducts and gall-bladder (cholangitis 
and cholecystitis), an attempt should always be made to control 
the infection by medical means ; for this purpose hot or cold ap- 
plications to the gall-bladder region should be made and con- 
tinued for several days. The choice of heat or cold will have to 
be made according to the subjective sensations of the patients. 

The bowels should be thoroughly cleaned out and kept clean 
by the administration of laxatives and enemata. Here a chola- 
gogue-antiseptic treatment with the salicylic acid and bile acid 
combination described above, to which may be added half a grain 
of menthol as an antiseptic and anesthetic, is useful. The follow- 
ing combination is also very popular for continued use : 



3 



Sodium benzoate 0.5 

Sodium salicylate 1.0 

In pill or capsule, to be given three or four 
times a day. (ChaufPard.) 



I consider the salicylic acid and bile acid pill, however, to be 
more efficacious. 



CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS 505 

The diet during this treatment should be bland and non- Diet 
irritating. During the first week of the bile passage infection, 
milk alone is best given, during the second week soups or thin 
gruels may be added to the milk, and during the third week and 
later a little meat and a gradual resumption of a general mixed 
diet may be allowed. 

If all these measures fail within a few months to relieve the 
inflammation, or sooner if the patient suffers from recurrent at- Surgical 
tacks of pain with or without icterus, and develops signs of gen- 
eral septic toxemia, loses much strength, becomes emaciated and 
anemic, recourse must be had to surgery. Opening of the gall- 
bladder, free drainage and irrigation usually produce prompt 
relief and, in most cases, constitute the only means of effecting 
a permanent cure of this obstinate and dangerous condition. 



treatment 



CHAPTER X. 



INFECTIOUS DISEASES 

INTRODUCTORY. 

Acute infectious diseases are in a sense self -limiting and dis- General indict 
play a tendency towards spontaneous recovery. The chief duty tl0n s for treat- 
of the physician, therefore, must be to imitate the methods put 
forward by Nature towards restoring normal conditions, wher- 
ever that is possible. Wherever, in the obscurity of our present 
knowledge, that is impossible, he should concern himself with 
creating ideal conditions about the patient in order to enable 
him to exercise his best efforts towards combating the infection. 
Here and there, besides, it may become necessary to strengthen, 
reinforce and stimulate reactive processes when they begin to 
flag; to hold them in check when they threaten to exceed safe 
bounds. Finally, various disorders about the different organs 
and functions of the body produced by the infection call for reg- 
ulation and symptomatic treatment. 

The specific (diphtheria), or antiseptic (syphilis, malaria, Specific anti- 
rheumatic fever), and specific prophylactic (small pox, tetanus, septic prophy- 
hydrophobia, tuberculosis [ ?] ) treatment of the disease is pos- ment 
sible only in a few infections. In all the others we are limited Expectant- 
in our endeavors and can only treat the patient by an expectant- symptomatic 
symptomatic plan. 

Provided the broad principles of hygiene and of the general 
management of the patient afflicted with an acute infectious dis- 
ease are understood and carefully applied, the basal treat- 
ment of most infectious diseases, for which we possess no 
specific remedy, is very much alike. In order to avoid unneces- 
sary repetition a few general remarks in regard to the rationale 
of fever treatment, and in regard to the principles that should 
underly the arrangement of the fever diet may be discussed in 
this place. 

THE TREATMENT OF FEVER. 

The treatment of the fever is an important element in all Treatment of 
acute infectious diseases. It is essential to realize that the fever 
fever, provided it is not too high nor too persistent, does not se- 
riously damage the organism. In fact, the febrile reaction must 
be considered one of Nature's most effective means of combating Fever a salu- 
the infection. Interference on the part of the physician is re- tar y reaction 
quired, therefore, only if the febrile reaction exceeds safe bounds. 
The old idea that the fever must at all costs be kept down was 



508 



INFECTIOUS DISEASES 



The normal au- 
tomatic fever 
mechanism 



The initial 
chill 



Radiation of 
heat via the 
pulmonary and 
the cutaneous 
route 



Fresh, cool air 
and hydro- 
therapy 



Antipyretics 



based on the erroneous idea that the parenchymatous changes 
seen in many organs during the course of acute infectious dis- 
eases were produced by the high temperature. Nowadays, we 
have learned to recognize that these lesions are caused by the ac- 
tion of circulating bacterial toxins. 

Upon the onset of •an infectious fever the high temperature 
is produced not only by an increased manufacture of heat but 
also by a decreased radiation of heat. The loss of heat is in- 
hibited chiefly by contraction of the cutaneous vessels, so that 
early in most infectious diseases the skin becomes cool and the 
patient suffers a chill. Sometimes this reaction presumably suf- 
fices to abort the infection. If this preliminary condition were 
to continue throughout the course of the disease the patient's 
temperature would rise to unsafe limits ; consequently, the radia- 
tion of heat is automatically resumed very soon after the initial 
chill chiefly by two paths, namely, by the pulmonary and the 
cutaneous route. This adjustment must be considered as a 
self-regulating mechanism. Inasmuch as the increased produc- 
tion of C0 2 which accompanies the initial febrile rise stimulates 
the respiration, more rapid breathing occurs, more water is ex- 
haled and considerable heat is lost in this way (each gramme 
of water evaporated in the expired air causing a loss of about 575 
calories). The loss of heat through the skin is promoted by 
sweating and the evaporation of surface water. (Sweating dur- 
ing the crisis serves a different purpose ; it must be considered as 
an endeavor on the part of the organism to rapidly get rid 
of the surplus water which was retained in the blood and tissue 
juices during the fever in order to maintain proper osmotic 
equivalents). 

In cases suffering from excessively high degrees of fever these 
methods that Nature spontaneously puts forward must be imi- 
tated. The pulmonary radiation of heat must be encouraged by 
supplying plenty of cool, fresh air (see Section on Pneumonia). 
The cutaneous radiation must be aided chiefly by hydriatic means 
(see Section on Typhoid). 

In addition certain remedies can be employed for their anti- 
pyretic effect. Here what may be called "central" as against 
"peripheral" regulation of the temperature is attempted, inas- 
much as most antipyretic drugs act on the central nervous ele- 
ments and paralyze the heat centers. In the latter case, there- 
fore, the manufacture of heat is reduced, whereas by the former 
method the radiation of heat is increased. 

In nearly all cases of acute infectious diseases one can get 



INFECTIOUS DISEASES 509 

along very well without antipyretic drugs, and they should be General indica- 
given very sparingly and with great care only in extreme cases c^ntra^ndica- 
in which high degrees of temperature cannot be reduced by the tions for the 
pulmonary or the cutaneous route. Antipyretics should, more- retic arugs Py " 
over, only be given intermittently and always in combination 
with heart tonics. Their use is rarely called for early in the 
disease arid they are useful chiefly when the tone of the heart 
and of the vaso-motor centers has begun to flag, when the self- 
controlling mechanism fails and calls for regulation by artificial 
means. It will generally be found that antipyretics exercise a 
much more profound and rapid effect precisely during these later 
atonic stages than during early sthenic periods of the infection. 

To enumerate all the antipyretic drugs that can be employed The chief anti- 
(and to this class, broadly speaking, belong remedies that act Pv retics 
directly on the fever-producing toxins like quinine and salicy- 
lates, drugs that paralyze the muscles (curare), drugs that par- 
alyze the peripheral capillaries and hence promote increased 
radiation) is unnecessary. The chief antipyretics to be employed 
are quinine, salicylic acid, antipyrin and its congeners, and alco- Quinine 
hoi. The dose and administration of these drugs and of certain Salicylic acid 
other antipyretics will be discussed below in their appropriate its conveners 
places. Alcohol 

THE FEVER DIET. 

The most important element in the feeding of febrile cases 
is to maintain the albumen content of the organism. The amount 
of albumen consumed by a fever patient and the degree of gen- 
eral emaciation that supervenes depend somewhat on the char- 
acter of the poison and the complications that arise. To main- 
tain complete nitrogen equilibrium is usually a very difficult task. 
The attempt, however, should always be made to introduce small 
quantities of albumen daily in some form, together with plenty 
of carbohydrate and some fat. Both fats and carbohydrates pro- 
tect the albumens of the body; the latter much more than the 
former, however, inasmuch as 100 fat calories can replace only 
5.4 albumen calories, while a hundred carbohydrate calories can 
replace 15.4 albumen calories. 

The demand for food is decreased in febrile cases and its as- caloric re- 

similation interfered with; at the same time the individual is quirements of 
n o ii ii ii- febrile organ- 

quiescent and performing no labor, so that the total caloric re- ism 

quirement, despite the increased metabolism, is lower than one 

might expect and can consequently be supplied much more 

readily than if the individual required a normal amount of 

caloric values to maintain nutrition. In a subject weighing about 



510 



INFECTIOUS DISEASES 



Milk 



8ug"ar solu- 
tions 



Gruels 



Gel;: .inous 
foods 



Fats 



Water 



seventy kilos the following ration theoretically calculated is usu- 
ally sufficient : 

50 gm. of proteid = 205 calories 

50 gm. of fat = 495 calories 

500 gm. of carbohydrate =2050 calories 

2720 calories 
or about 30 calories per kilo.* 

In practice the following general rules of feeding sufficiently 
approximate the above requirements. Albumen should be sup- 
plied in the form of one or two eggs in some shape daily, or in 
the form of milk ; the latter being the most valuable fever food of 
all, inasmuch as 1000 cc. of milk incorporate 35 grammes of pro- 
teid, 35 grammes of fat and 45 grammes of sugar, representing 
a total caloric value of 650 calories. The addition of abundant 
carbohydrate to milk, in the form of sugar solutions or gruels 
made of milk and flour, barley, arrowroot, sago and tapioca, 
usually suffices to bring the daily ration up to the required ca- 
loric value. Proteids may also be supplied in the form of gela- 
tins, meat jellies, etc., and other liquid and semi-liquid meat 
products, the preparation of which is described in the Section on 
Typhoid Feoer. The fats should be given in small quantities 
and supplied only in the form of cream, or as a little butter 
added to gruels, or in the small quantities of meat fat that re- 
main in the meat preparations that can be administered. Alco- 
hol in small quantities, aside from its antipyretic properties, con- 
stitutes a useful food in fever cases, especially as it possesses 
very marked albumen sparing properties. 

"Water should always be given in abundant quantities in fever 
cases, not only in order to quench the thirst and to dilute the 
toxins, but to relieve the organism of the necessity of manufac- 
turing water from its own tissues, thereby splitting up complex 
molecules and flooding the blood and tissue juices with waste 
products. A febrile patient should be offered a drink every fif- 
teen to thirty minutes during the day, alternating the beverage, 
i. e., offering milk, soups, lemonade, a little wine, coffee, tea and 
water. 

The following fever diet, which is employed as a routine in 
the Charite Hospital in Berlin, may serve as a prototype of an 
average fever diet: — 

For breakfast 500 cc. of milk sweetened with plenty of sugar 
and flavored with a little coffee. 

For dinner 250 cc. of meat broth. 



♦See also chapter on Diseases of Me tabolism. 



PNEUMONIA 511 

In the middle of the afternoon 500 cc. of milk, with sugar and 
coffee as above. 

For supper 250 cc. of gruel made of milk* and flour. 
Distributed over these four meals 80 grammes of rolls, toast 
or zwieback. 

The following dietary constitutes a daily ration which about 
meets all requirements: 

1000 cc. of milk = 650 calories 

2 eggs = 150 calories 

400 cc. barley gruel = 200 calories 

100 g. zwieback or toast = 350 calories 

100 g. cane or milk sugar = 410 calories 

200 cc. of Tokay or port wine = 300 calories 
Total =2070 calories 

In. arranging a dietary, finally, the state of the digestive state of the 
function must be carefully included in the calculation. Both digestive func- 
the fever and the toxemia affect the digestive organs in the sense 
that the amount of saliva and its amylolytic power are reduced, 
that the motor and secretory powers of the stomach and bowel 
.are impaired and the flood of bile is decreased. 

These perversions of the digestive function are reflected in 
the loss of appetite. In cases of fever in which there is a com- 
plete distaste or aversion for food, rectal feeding (see index) Rectal feeding 
may therefore have to be resorted to. 

An important element, finally, in maintaining the proper nu- 
trition of fever patients is to perform a careful toilet of the To11 ®* °* tlie 
mouth, as described in the Section on Stomatitis. 

In the following pages those infectious diseases that are 
amenable to specific treatment have been discussed in full, where- 
as of the large group of infections that must be treated by the 
expectant-symptomatic plan, only the most important and the 
most common members have been specially noted. In order to 
avoid useless repetition in this volume the treatment of the com- 
plications occurring in different organs has only been touched 
upon, for full symptomatic treatment of the different organ 
lesions has been already described in the preceding chapters. 



PNEUMONIA. 
(By Dr. E. F. Wells, Chicago.) 
Pneumonia is a widely prevalent and very dangerous dis- 
ease ; in temperate regions it is responsible for more deaths than 
any other malady; its prevalence and dangers, measured by any 



512 



PNEUMONIA 



Materiel 
morbi 



Prophylaxis 



rule which you may choose to apply, are increasing with each 
passing year; it§ treatment is the greatest and most pressing 
medical problem of the day. "What can we do to lessen its prev- 
alence and reduce its mortality? These are the questions, shorn 
of all minor and collateral issues, which are presented for our 
careful consideration. 

Pneumonia is caused by the pneumococcus. This bacterium, 
in one or another of its varieties, you may find in the upper re- 
spiratory passages in a large proportion — probably one-half — of 
all healthy persons. It is disseminated through the air which has 
become pneumococcus-laden by the spray produced in coughing 
and sneezing, and from dried and pulverized sputum of infect- 
ed, but not necessarily pneumonic, individuals. If such air is 
inhaled by a healthy person the germs may find permanent 
lodgment in his nose and throat. In this locality the pneumococcus 
is probably an innocent parasite, but if it finds its way into the 
pulmonary alveoli pneumonia results. The entrance of this organ- 
ism into the air cells may be invited by any condition which ren- 
ders paretic the laryngeal and bronchial reflexes. It is found 
in the circulating blood, early — I have recovered it within an 
hour of the initial chill — in a very large proportion, if not all, 
of the cases. Intercurrent or independent pneumococcal in- 
flammation, with sanguineous infection of other organs and tis- 
sues, as, e. g., endocardium, articulations, peritoneum, etc., may 
occasionally occur. The various strains of the pneumococcus 
vary in virulency, and those which are most virile obtain the 
widest distribution and create the greatest havoc. 

With the basic etiological facts fully appreciated we are 
prepared for an intelligent consideration of the prophylaxis of 
this malady. This I believe to be the most important and most 
hopeful section of the whole pneumonia question, which is com- 
mended to the earnest attention of the profession. 

In the case of each individual under professional care the 
tonsillar surface secretions should be examined for the pneumo- 
coccus. If a Gram positive encapsulated diplococcus (or strep- 
tococcus) • is obtained it may be considered, for this purpose 
only, sufficient evidence of the presence of the pneumococcus 
Such examinations should be repeated at intervals, in order to 
have fair knowledge whether the patient is, or is not, affected. 
Keep a record of, and report to him, your findings. With the 
throat free from pneumococci the individual is practically ex- 
empt from pneumonia. 

For the medical practitioner I recommend the following 



1 gm. 


2 gm. 


200 


ec 


0.5 


cc 


10.0 


cc 


10.0 


cc 


4.0 


cc 


60.0 


cc 



PNEUMONIA 513 

technique: Rub a sterile cotton swab over both tonsils; make Technique of 

<jover-glass spreads ; dry, and fix with heat. Have prepared the determination 

& ^ ' J ' of micro-or- 

f olio wing solutions: g-anism 

A. — Gentian violet solution: 

Saturated alcohol solution gentian violet, 6 cc. 
Alcohol, 10 cc. 

Glycerine, 10 cc. 

Carbolic acid solution, 95%, 4 cc. 

Water, distilled, 60 cc. 

B. — Iodine solution : 
Iodine, 

Iodide of potassium, 
Water, distilled, 

(J. — Fuchsin solution: 

Saturated alcoholic solution fuchsin, 

Alcohol, 

Glycerine, 

Carbolic acid solution, 95%, 

Water, distilled, 

Stain the specimen with the gentian violet solution for one 
minute; wash well in water; apply the iodine solution for two 
or three minutes ; wash ; decolorize thoroughly with alcohol ; wash ; 
counter-stain with the fuchsin solution, heated, for one 
minute; wash thoroughly; dry; mount; examine with one- 
twefth oil immersion lense. Pneumococci stain intensely violet 
or blue, almost black at times; the capsules remain uncolored, 
contrasting sharply with the deep stain of the organisms and the 
rosy or brilliant red of the general field. When pneumococci 
lie upon or beneath an epithelial cell the capsule may present a 
pink or rosy hue, due to the staining of the cellular protoplasm. 
Sometimes the pneumococci are in chain formation, with either 
a continuous sheath-like capsule, or with the ends of the diplo- 
coccal capsules joining end to end. The streptococcus mucosus 
(capsulatus) takes this (Gram) stain, is found alone in some 
cases of pneumonia, ferments inulin, coagulates inulin-water- 
serum and should be classed as a variety of the pneumococcus. 
All streptococci retain the stain well; staphylococci and diph- 
theria bacilli stain in lighter shades ; tubercle bacilli stain a deep 
or brilliant red; Friedlander's bacillus and the influenza bacil- 
lus are stained pink or rosy red. 

The capsule of the pneumococcus may be stained with 
Wright's or other methylene-blue-azure stain, or by Welch's 



514 PNEUMONIA 

or His's stain. Differentiation may be more closely made by 
various cultural, fermentation, agglutination and animal inocu- 
lation tests, a consideration of which is beyond the scope of this 
treatise. For further information reference is made to the cur- 
rent literature. 

If pneumococci are not found in the throat every reasonable 
precaution should be taken to prevent future infection. The 
mouth, nose and throat should be kept as clean as possible. 
Unclean fingers, money and other articles which are promiscu- 
ously handled, should be kept out of the mouth. Antiseptic nasal 
sprays, mouth-washes and gargles may be used. The teeth and 
mouth generally should be frequently and carefully cleansed; 
water should be swallowed after eating; mouth-breathing should 
be avoided. The nasal passages should be kept as free as prac- 
ticable from accumulations of mucus; if there are organic ob- 
structions they should be removed. Hypertrophied and honey- 
combed tonsils should be ablated or otherwise properly treated. 
Extraordinary efforts should be made to avoid crowds of cough- 
ing and sneezing persons, and to keep well beyond the range of 
possibly pneumococcus-laden air. Eesidence in regions where 
the pneumococcus is rare may be considered. The obvious in- 
tent in instituting all these measures is, as must be evident, to 
avoid or minimize the risks of invasion, or prevent lodgment 
of the pneumococcus in the upper respiratory passages. 

If the pneumococcus once finds infective lodgment in this 
region it remains, so far as I know, a permanent resident, im- 
possible of dislodgement by any known means. The individual 
is now liable to pneumonia at any time, although he may pass 
through life without an attack. Under these circumstances, not- 
withstanding our best efforts, pneumonia cannot always be pre- 
vented; it may, however, be invited, and such invitation should 
not be intentionally extended. 
Communal In the case of the infected person the measures above rec- 

pro ec ion ommended for the uninfected should be followed, with the hope 

that the virulency of the organism may be reduced, and that 
the infection may be least likely to extend to others. He should, 
in addition, avoid the excessive, and even the so-called moderate, 
use of alcohol, or any other drug which will render paretic the 
reflex nerves which stand sentinels at the portals of, and along 
the course of, the deeper respiratory tracts. For the same rea- 
son undue exposure to cold and inclement weather; privation; 
physical and mental exhaustion; profound sleep when chilled 
or over-tired ; all should be avoided. The chances of contracting 
diseases, as, e. g., typhoid fever, measles, smallpox, etc., which 



PNEUMONIA 515 

may lay the foundation for pneumonia, should be minimized; 
should they develop special attention should be given to the 
preservation of the respiratory reflexes. Anesthetics should be 
-employed with caution, and only after careful preparatory cleans- 
ing of the nose, mouth and throat. 

Impressively advise those who harbor the pneumococcus to 
carefully avoid disseminating the infective organism, and pa- 
tiently instruct them how this may be done. Such persons 
should, in coughing, sneezing and blowing the nose hold a mois- 
tened cloth before the mouth and nostrils in such manner as to 
prevent the projection into the surrounding air of the fine, 
probably pneumococci-bearing spray which ordinarily follows 
these explosions. In pneumonia the sputum which clings so 
persistently to the teeth and lips, and that which may adhere 
to the fingers and bedding, should be wiped up with moistened 
gauze or other cloth and these burned. That which is freely 
■expectorated should be caught in a vessel which may be boiled, 
thus destroying the germs and cleansing the receptacle. In 
some efficient manner all sputum should be destroyed. A room 
which has been occupied by a pneumonic patient should be dis- 
infected. 

For additional communal protection there should be dis- 
plaj^ed in all public places placards bearing the legend : 



' ' WHEN COUGHING OR SNEEZING HOLD HANDKER- 
CHIEF BEFORE YOUR MOUTH AND NOSE. 7 ' 



In addition, the advice given in the preceding paragraph, 
formulated into plainly stated and available rules, should be 
widely and persistently circulated among the laity by the re- 
sponsible health officers. A supply of these rules, neatly printed, 
but without imprint, should be furnished practising physicians, 
with the request that they give them as their instructions to 
their patients and clientele. 

Finally, not only maintain your own enthusiasm in this mat- 
ter, but by every means within your power arouse and foster 
the interests of other physicians and humanitarians in this sub- 
ject. For example, take the initiative in organizing special com- 
mittees and societies for the purpose of stimulating the study 
of the problem and reinforcing the efforts of the various health 
bodies, as has been so successfully done in the case of tubercu- 
losis. 



51G 



PNEUMONIA 



At this point it behooves the conscientious physician who 
may be called upon to treat cases of pneumonia to take stock 
of himself in order that he may decide whether he should, in 
all fairness, assume such a grave responsibility. If he possesses 
the necessary knowledge ; if he has observed and managed a num- 
ber of cases of this disease; if he has sufficient physical endur- 
ance ; if he is free from impairing drug habits ; if he has at all 
times a good and unclouded judgment; if he has executive abil- 
ity; if, in addition, he possesses self-confidence he may safely 
undertake the management of cases of this serious malady. On 
the contrary if, because of lack of opportunity, inherent inca- 
pacity, or acquired habits, he finds himself lacking in the above 
essentials he should decline to treat these cases. 

With the failure of preventive measures and the develop- 
ment of pneumonia, how shall the patient be managed that his 
every interest may be best conserved? 

Initial care Assuming that your patient is a middle-aged adult, of pre- 

vious good health; with no drug habits; in easy pecuniary cir- 
cumstances; that the environment is ideal; that you see him at 
the beginning of the attack; that the diagnosis is made; under 
these conditions much is required and much is to be done at the 
first visit. 

At the beginning of the attack the patient should be placed 
in bed, surrounded by bottles of hot water, and given, hypoder- 
mically, one-twelfth or one-eighth grain of morphia, for the pur- 
pose of relieving the pain, allaying nervous excitement and re- 
storing circulatory equilibrium. He should lie quietly until 
the chill has subsided, when the hot water bottles should be 
removed and the perspiration wiped from the surface of the 
body. The bowels should now be evacuated by an enema of two 
ounces of Epsom salts, two ounces of glycerine and twelve 
ounces of water ; later an efficient cathartic should be given. 

The sick room The sick-room should be large, well ventilated and with 

south, east and west exposures. It should be comfortably fur- 
nished, including two narrow beds of suitable height. Bath- 
room and other modern conveniences should be adjacent. There 
should be provision for regulating the temperature, that the air 
may be comfortably warmed in winter and cooled in summer. 

Nurse A nurse and an assistant will be required. The nurse should 

have inherent ability, diligence, acute observation, good judg- 
ment, abundance of reserve capacity, excellent training and rea- 
sonable experience. Her assistant should be thoroughly compe- 
tent. She should be given written directions, which may be, 
approximately, as follows: 



First medica- 
tion 



PNEUMONIA 



517 



DIRECTIONS FOR THE NURSE. 

1 —Follow the ordinary rules of good nursing, including, par- 
ticularly, keeping awake, alert, attentive and closely observ- 
ant at all times; keeping of full and accurate records; the 
prompt report of striking, unexpected or important changes 
as they occur. 

2.— Keep the room at an equable temperature, 65° to 70° F., as 
may be agreeable to the patient. The humidity should be 
moderate. The air should be fresh and pure. There are 
no objections to agreeable odors. 

3, — Promiscuous visiting should be prohibited; no one should 
be admitted to the sick room except those specifically desig- 
nated by the physician. The consideration of business prob- 
lems is highly objectionable. Quietude of mind and body 
should be favored by maintaining a general air of hope- 
fulness. 

4. — The patient should be confined to his bed; his position 
should be changed often, but in such manner as to cause 
the least discomfort; he should be generally handled with 
gentleness, in bathing, in the use of the bed-pan, in chang- 
ing his clothing, etc. The narrow bed should be so placed 
as to permit approach from either side; one bed should be 
used during the day, the other at night; in moving the 
patient from one to the other bed, place the beds side by 
side and slide him across with the sheet, two persons be- 
ing necessary. The mattress should be elastic, the pillows 
soft, the sheets of thin woolen goods, and the covers light. 
The night-dress should be of thin woolen, or silken, goods, 
and so arranged as to afford easy access to all parts of the 
chest. 
5. — The surface of the body should be bathed twice daily with 
warm water, to which a little Cologne water has been added. 
If there is a tendency to chilliness the bathing should be 
done under the covers. The face and hands may be bathed 
as often as required. If there should be much perspiration 
the surface should be wiped dry, gently rubbed with a cloth 
dampened with alcohol and a drying powder applied. The 
ice cap should be used if the temperature runs high, or if 
the head aches, provided it is not disagreeable. The hot 
water bottle, or the electrotherm, should be used if the ex- 
tremities become cold; if agreeable they may be applied to 
the painful side. 
G. — The patient should be encouraged to restrain ineffectual 
coughing as much as possible. The expectoration should be 



518 PNEUMONIA 

caught upon moistened gauze and preserved for the phy- 
sician 's inspection ; that which clings to the lips, or f alls- 
upon the floor or clothing, should be wiped up; all sputum 
should be destroyed before it has become dried. The mouth 
should be kept clean. All utensils, and other articles which 
come in contact with the mouth or sputum, shoud be scrupu- 
lously cleansed and disinfected. Later the room should be 
disinfected. 

7. — Nourishment should be given as follows : — Four times a day,, 
at six hourly intervals, the patient should be given one egg,, 
a piece of toast and a glass of milk. The egg may be given 
in any form desired. The milk may be cold or hot, with or 
without lime water or Vichy, peptonized, fermented or 
soured, or in the form of milk soups, cocoa, caffe au lait r 
etc., as required to meet the tastes or digestive needs of the 
patient. Three hours after each of these feedings there 
should be given a half -pint of well seasoned and agreeably 
flavored beef, mutton or chicken broth. At other times there 
should be given water, carbonated waters, fruit juices, tea,, 
coffee, etc., to such an extent that the patient receives a 
total of about eighty ounces of liquids, of all kinds, in the 
twenty-four hours. The salt used should have added to it 
1 per cent, of sulphate of lime, and it should be used as 
freely as it can be borne. If solid foods are objected to the 
toast may be omitted. If nausea or vomiting preclude gastric 
nourishment enemas, to be retained, of eight to sixteen 
ounces of coffee, with forty to eighty grains of table sah% 
and three to six grains of chloride of calcium, should be ad- 
ministered every four to six hours. 

8. — The first night give two five grain pills of blue mass, fol- 
lowed next morning by a half bottle solution of citrate of 
magnesia. Later the bowels should be made to move twice 
daily by enemas ; that in the morning should be a large nor- 
mal salt flushing one ; that in the evening should be the stim- 
ulating one of sulphate of magnesia and glycerine above 
mentioned. The latter enema should be used at any time if 
there should be intestinal paresis with abdominal distention. 
The mixed twenty-four hours' urine should be preserved 
and a two ounce specimen, and one ounce of recently passed 
urine, furnished the physician daily for analysis. 

NOTES. 

a. — The patient should be given every needed and ordered at- 
tention, but excessive and fussy attention should be avoided; 
he should be allowed sufficient rest when awake, and should 



PNEUMONIA 519 

not be awakened from sleep. There should be no rustling 
of skirts/ rattling of utensils nor clattering noises allowed. 
In his presence the patient should have the undivided at- 
tention of nurse and physician ; for the time he is the center 
of the world, 
b. — The nurse should be especially instructed as to the signifi- 
cance of certain symptoms and conditions, and as to the 
initial management of some of the most serious complica- 
tions: — In some cases of observant delirium the patient 
should be very closely watched, in order that he may not 
elude vigilance and escape. In the slight but gradually in- 
creasing duskiness of the surface, and blueness of the nails, 
of early cyanosis, oxygen should be promptly administered. 
In the spreading ashiness of the surface, with changed char- 
acter of the cough and serous expectoration of pulmonary 
edema, the foot of the bed should be raised sufficiently high 
to make the mouth and nostrils the lowest portion of a drain- 
ing inclined plane, and a hypodermic injection of one- 
twelfth grain of morphia, one one-hundred and fiftieth grain 
of atropia and one-thirtieth grain of strychnia should be im- 
mediately given. In the late surface glow, with increas- 
ing frequency of the pulse and slight capillary and venous 
pulse, which is the beginning of a dangerous vaso-motor 
paresis, there should be administered, under the skin or 
deeply in the muscles, one or more syringefuls of a five per 
cent, solution of camphor in sterilized olive- oil. It is need- 
less to say that proper provision should be made for all these, 
and other contingencies. 
c. — The nurse should be informed that late sneezing is of good 
augury ; that the slight respiratory click, which does not at- 
tract the attention of observers generally, and which prompt- 
ly returns after being silenced by a cough, is of ominous im- 
port. 
At this place it may be well to make some preliminary state- 
ments which will clear the way for more rapid progress: — 

Have we an efficient specific treatment of pneumonia ? It is Morbid pro- 
well known that the pneumococcus, in the blood, and in the cesses 
hepatized lung, produces certain substances which are as yet 
known only by their effects, as e. g., the initial chill and nervous 
shock, the prompt occurrence of capillary dilatation and leu- 
cocytosis, later the appearance in the intra- and extra-vascular 
serum of a specific agglutinin, and yet later the production of a 
toxin which speedily causes the pneumococcus to disappear from 
the blood. These facts have led to reasonable expectations that 



520 PNEUMONIA 

there might be prepared an anti-pneumococcic serum which, 
when introduced into the circulating intra- and extra-vascular 
serum of the pneumonic patient, would speedily, and certainly, 
cure the disease. In my opinion, such sera, reliably efficient, 
have not yet been produced. It is noticeable that, with a pro- 
fession eagerly awaiting the advent of such sera, those thus far 
placed upon the market have signally failed to meet that favor at 
the hands of clinicians which is quickly and enthusiastically 
awarded therapeutic novelties of real value. However, analogy 
leads us to believe that a useful antipneumococcic serum may 
be produced, and I remain hopeful that this will be early ac- 
complished. 

The pneumonic crisis corresponds so closely in point of time 
to the extinction of the infecting organism that we are forced to 
the conclusion that it is the death of the pneumococci, and not 
the neutralization of their toxins, which is the event which must 
precede recovery of the patient, and experiments only strengthen 
this conviction. A pneumonia antitoxin is, therefore, not to be 
expected, and none has been produced which has attracted any 
favorable therapeutic consideration. 
Abortive cases The abortion of pneumonia has always attracted much atten- 

tion. In the ephemeral cases, with recovery in one, two or three 
days, there is probably infection by a very weak strain of the 
pneumococcus, which is early and readily destructively affected 
by the developed toxins. Possibly there is erected a protective 
barrier, which is efficient against so virile an organism, by the 
leucocytes, those active motile glands which swarm into the cir- 
culation as defenders of our bodies when its integrity is threat- 
ened by the invading foe. If such cases have been submitted 
to treatment we should hesitate before attributing the happy 
result to the therapeutic measures which may have been em- 
ployed. 

Eeturning now to the patient, seize the first opportunity to 
obtain specimens of the blood and urine, for examination. 

The blood should be examined daily, or oftener, including 
an enumeration of the red and white corpuscles and a differentia] 
leucocyte count. Wright's (or similar) stain you will find most 
satisfactory. Occasionally pneumococci may be detected in the 
preparation. Cultures should be made early, and repeated when- 
ever special information is required as to the characteristics of 
the pneumococci. The blood should be obtained from a vein 
at the bend of the elbow ; the skin should be scrupulously cleansed 
and the needle or syringe perfectly sterilized. Three to five cc. 
of blood to 100 or 150 cc. of plain or glucose bouillon is a desir- 



PNEUMONIA 521 

able proportion. With every opportunity, and in special cases Scheme of crit- 
the opportunity should be made, the serum should be examined t i on 
for urea. Whenever hemoglobin appears in the urine the serum 
of the blood should be examined for hemoglobin. The daily ex- 
amination of the urine should include, especially, the quantity in 
twenty-four hours, total solids, total urea, total chlorides, total 
sulphates, proportion of phosphates, proportion of indican, and 
•casts. 

The pneumococcal toxin must be one of extraordinary viru- 
lency. We have all marveled at the profound impression made 
upon the patient 's system by the introduction into the nutritional 
fluids of the body of an infinitesimal quantity of the pneumo- 
coccal toxins, and these diluted beyond computation, as evidenced 
by the profound chill, raging fever, complete prostration and 
other equally notable phenomena. Among the latter the first 
to attract attention is the remarkable reduction of the arterial 
tension, which is one of the earliest and most persistent of the 
symptoms of the disease. This is probably an efficient provision 
of Nature for mobilization of the reserve army of leucocytes into 
the circulatory current for the purpose of protecting the tissue 
cells from the irritating and paralyzing effects of the pneu- 
mococcal toxins. 

Certain other consequences of this capillary paresis may 
be noted : — The blood with each ventricular systole is directly 
projected through the capillaries into the veins; the venous sys- 
tem becomes overfilled while the arteries become correspondingly 
underfilled ; capillary osmosis is greatly reduced and the extra- 
vascular serum becomes more or less stagnant; the tissue cells 
lack their accustomed stimulus, are insufficiently nourished and 
are constantly bathed in a solution of their own waste ; later, 
with returning vascular tone, these waste materials will enter 
the general circulation. It should be here noted that as the mal- 
ady progresses, with rapid multiplication of bacteria and greatly 
increased production of toxins, the effects above noted are not 
correspondingly intensified. This may be due to a variety of 
causes, as, e. g., temporary paresis of the hypothetical sensitive 
norns of the nerve cells; simple accommodation to an irritant; 
intra-vascular retention of toxins; dilution, or deterioration, of 
those held extra-vascularly ; their absorption by protecting cellu- 
lar elements; their neutralization by leucocyte secretions. 

Under these circumstances what shall we do? Shall we as- 
sume that Nature is right, but incompetent, and, following her 
lead, attempt to further facilitate the escape of the blood through 
the capillaries by the administration of such agents as nitro- 



522 



PNEUMONIA 



Veratrum 
viride 



Venesection 



glycerine, iodide of potassium, veratrum viride, etc. ? Shall we 
presume that Nature is mistaken and attempt to correct her error 
by having prompt recourse to adrenalin, digitalis, etc.? Shall 
we assume that Nature is correct in theory and practice, or shall 
we acknowledge our ignorance in the premises, and in either case 
forbear active interference? These are practical questions of 
great importance. Practically I am inclined, in the ordinary 
case, to supplement the evident efforts of Nature by giving, dur- 
ing the first few hours only, two or three drops of fluid extract 
of veratrum viride every one to three hours until slight nausea 
has been induced, or the initiatory surprise of the attack has 
passed. 

This remedy, a variety of which was used by Gessner in the 
VI. century, was brought into considerable prominence by~ 
Norwood and other American physicians in the second third of 
the last century. In pneumonia it quiets and retards the excited 
and rapid heart, while increasing the volume of blood forced 
through the arteries without increasing the peripheral tension. 
If the tincture is used it should be noted that the last revision 
of the U. S. pharmacopoeia has reduced the strength seventy-five 
per cent. 

Aconite, iodide of potassium, nitro-glycerine and other agents 
having similar actions offer no advantages over veratrum viride. 

In those cases with increasing nervous perturbation, exalted 
temperature, circulatory excitement, cerebral and general con- 
gestion and thoracic oppression during the first or second day,. 
moderate or free bleeding — twelve to twenty-four ounces — 
should be practised. By this procedure the pneumococci and 
their toxins are immediately reduced by a moderate or consider- 
able proportion. If now liquids are largely introduced into the 
circulation, by the mouth, by the rectum, or by hypodermoclysis,. 
the remaining morbid matters are further diluted. Blood-let- 
ting at this time gives great and speedy relief, apparently bridg- 
ing over a period of stress until the system, in the ordinary 
course of events, accommodates itself to the pathological burden. 
This procedure I have practised a great many times under these 
circumstances and always with satisfaction ; never with regret- 
Venesection is not required in every case; the patient should be 
selected most carefully; likewise the conditions and the time. 
You should not bleed the very young, the very old, the anemic 
nor the weak. 

One hundred and sixty years ago Cleghorn observed that 
which holds true to-day, namely, that in pneumonia the tem- 
perature rises, in the afternoon, to the 102d, and iu severe cases 



PNEUMONIA 523 

to the 104th, degree of the Fahrenheit scale. There can be no Temperature 
doubt that, as a rule, high corporeal temperature marks the se- 
vere case, but it does not necessarily follow that the exalted tem- 
perature is in itself detrimental and should be directly reduced. 
Nevertheless I am quite sure that, generally, patients who have 
much fever are rendered more comfortable by some of the meas- 
ures which may be employed with an antipyretic effect, and I 
therefore recommend their use. 

Of the legion of antipyretic measures I may mention the fol- Heat reducing- 
lowing as most worthy of confidence : — The ice cap, or cold water means 
coil, more or less persistently applied. The cold water coil ap- 
plied to the chest or abdomen; surrounding the patient, not too 
closely, with bottles of cold water. Sponging with cool water; 
sponging with warm, or hot water, followed by a cloth damp- 
ened with alcohol, with more or less exposure to the air, still or 
in motion, to promote evaporation; these to be repeated more or 
less frequently as required. These measures I have found suffi- 
cient in the vast majority of cases. In some cases, during the 
first, possibly the second day, four grains of acetanilid every Antipyretic! 
three hours until three or four doses have been given; in addi- 
tion to reducing the temperature moderately it will have a happy 
effect in relieving the headache and general aching which are 
so often present at this time; later it should not be used. In 
the exceptional case, with persistently rebellious high temper- 
ature, we may apply to the surface, wherever the skin is thin, 
fifteen to twenty-five drops of guaiacol; twenty drops is a fair 
initial dose, which may be increased at subsequent applications 
if required to produce the characteristic fall in temperature and 
sweating ; once the proper dose has been found it will not be nec- 
essary to either lessen or augment it. The gradually rising high 
temperature of the terminal stage can not be safety reduced by 
any means. 

In this connection cold packs, cold baths, aerial refrigera- 
tion, quinine in large doses, the legion of coal tar preparations, 
etc., are only mentioned to caution you against their employment 
as antipyretics. 

The pain of early pneumonia is usually severe and distress- Fain 
ing ; sometimes agonizing. It gradually subsides and ceases spon- 
taneously within three days. It will be moderately relieved by 
the initial small dose of morphia which I have recommended. 
During the first two or three days we may, with benefit in some 
cases, apply one or two strips of adhesive plaster to the affected 
side, extending the ends somewhat beyond the sternum and spine, 
so as to limit the extraordinary and painful respiratory excur- 
sions induced by the cough. 



524 



PNEUMONIA 



Local meas- 
ures 



Cough 



Inasmuch as the pain may be entirely relieved by morphia, 
and because relief in this manner is recommended by many au- 
thors, I consider it my duty to enter an emphatic protest against 
such treatment. Morphia given in sufficient quantity to relieve 
the pain throughout the painful period will obscure the sympto- 
matic field, dangerously paralyze the nervous reflexes and induce 
a false sense of security which, I believe, distinctly jeopardizes 
the patient's life. It is true that the minute dose advised may 
be repeated once or twice in the exceptional case, yet in my own 
practice this is seldom indicated. 

The local application of heat often mitigates the pain, and 
if it accomplishes this object it may be used. The same may be 
said of ice bags. 

Leeches, dry or «wet cups, sinapisms, stimulating liniments, 
blisters, fomentations, poultices, etc., I do not use. Neither do 
I employ the so-called pneumonia jacket. It may be said of many 
of these local applications that they are simply useless; others 
are harmful. 

During the early days of the attack the cough is usually 
frequent and painful; later it may be severe and distressing. For 
the relief of this symptom I direct that the temperature and 
moisture of the air in the sick room be maintained very equably, 
and that in every way the patient be kept as quiet as possible. 
The patient, by having his attention directed to the fact, and 
by reasonable encouragement, may exercise a very considerable 
restraint over the cough. 

The early small dose of morphia, and the strapping of the 
affected side will relieve, somewhat, the cough. Codeine may 
be used with reluctance; I have seen no case in many years in 
which it seemed indicated. Heroin I consider very objectionable. 
The same may be said of Dover's powder and other deceiving 
preparations of opium. Terpine hydrate has been reputed use- 
ful; I have used it many times without having observed bene- 
ficial results. Inhalations of chloroform have had their day. 
The bromides, and sedatives generally, are to be condemned. 
Should I encounter a case requiring a cough-restraining remedy 
my choice would be in favor of minute — ODe-sixtieth grain — 
doses of morphia, with a drop of chloroform, in a pleasant syrup ; 
such cases, I am sure, are very rarely encountered. 

The so-called expectorants, of which iodide of potassium is 
probably the only one of real efficiency, I do not employ. 

The questions which I have presented are those which will 
demand consideration, and decision, very early in the attack, 
but others arise with surprising promptitude. For example: 



PNEUMONIA 525 

after the initial nervous shock has been relieved the veratrum 
viride should be discontinued, with the question of interference, 
or non-interference, in the circulatory disturbance again before 
you for consideration. My own practice is to now give small 
doses — ten to fifteen drops — of a reliable tincture of digitalis Circulatory 
every four to six hours. Later, with any evidences of further 
vaso-motor paresis, the dose is increased to twenty to thirty drops 
and the interval, possibly, shortened. The object being to keep 
the arterioles and capillaries stimulated to moderate contrac- 
tion, and the dosage and frequency of administration modified 
from time to time as required to produce this effect. In times 
of special need the dose may be large, as, e. g., forty to sixty 
drops, which may be given hypodermically, provided a non-irri- 
tating tincture is employed. 

Leucocytosis, particularly manifested by a large proportional Leucocytosis 
and absolute increase in the polynuclear cells, appears promptly 
upon the advent of pneumonia, and continues throughout the at- 
tack. The eosinophiles are practically driven out of the periph- 
eral circulation, their reappearance coinciding with the earliest 
decline in pathogenic activity. To any one who gives the sub- 
ject observing and reflective consideration it must be evident 
that leucocytosis plays an important protective role, although the 
exact nature of this defense may not be known. It is probable, 
however, that these mobile secretory glands discharge their 
faintly alkaline secretion into the sanguineous serum, where it 
acts upon the pneumococci and pneumotoxins, and finding their 
way without the vessels acts in a similar manner in the extra- 
vascular toxins. Now it is well known that in some cases leu- 
cocytosis fails to appear, or is slight and inefficient; also that 
in such cases the death rate is, with exceptions, greatly in excess 
of that pertaining in those accompanied by leucocytosis to the 
ordinary degree. From these facts it is reasonable to conclude 
that it were best for us to stimulate leucocytosis, if possible, in 
those cases in which it is deficient. This I believe can be accom- 
plished, without risk, by the use of nucleinic acid, and I therefore 
give, in these cases only, one-half to one teaspoonful of a five per 
cent solution every three to six hours as required to produce the 
desired results. 

As the result of some desultory observations which I have 
made during the past five or six years I am prepared to say that Oxygen 
in many, if not in a great majority, of cases in which nucleinic 
acid is given it will be found that the blood platelets will be 
reduced in number and the coagulability of the blood noticeably 
diminished. Might this agent not be properly employed for 



526 PNEUMONIA 

the purpose of preventing the formation of cardiac and vascular 
thromboses? This I can only offer as a suggestion. Because of 
their known tendency to increase the proportion of blood plate- 
lets, and the coagulability of the blood, lime and gelatine should 
not be used in pneumonia. 

None of the pneumonic phenomena are more remarkable than 
the great diminution, or disappearance, of the chlorides from the 
urine. This is probably due to their being required in the system 
for purposes of defence against the pneumococcal toxins, or the 
pneumococcus itself; or for the retention of diluting liquids in 
the extra-vascular spaces. Should we emphasize these efforts of 
Nature and systematically use sodium chloride as a therapeutic 
agent? This I answer affirmatively, and advise you to give it 
with such freedom, by mouth, by rectum, or hypodermically, that 
it will not disappear from the urine. Personally I prefer to find 
a moderate amount of chlorides in such urines. 

At this time, before it is required, have on hand a supply of 
oxygen. It will probably not be needed early, but it is so useful 
at the very beginning of respiratory embarrassment due to de- 
fective aeration, and its employment is so likely to be then neg- 
lected, if not at hand, that I consider this preparation of prime 
importance. You are now ready to make use of this agent, freely 
and frequently, at the very beginning of that slight but steadily 
progressive increase in frequency and shallowness of breathing 
which when observed by the experienced practitioner fills him 
with well-founded apprehension. When once begun oxygen will 
probably be required until convalescence has been declared. 

The measures which have been mentioned will be found ap- 
plicable, with modifications, to the ordinary case during the first 
two or three days of the attack. Beyond this adaptations, dele- 
tions and additions may be required; certainly the physician 
should sharpen his wits and redouble his watchfulness in order 
that he ma} r anticipate, and not simply recognize, the earliest 
manifestations of those portentous conditions which often ap- 
pear with such remarkable celerity. For example: — 
Sleeplessness In some cases early disturbed sleep may become marked in- 

somnia, usually with an unimpaired, or even sharpened intellect 
— an ominous symptom indicating profound toxemia. To suc- 
cessfully combat this condition will tax to the full one's thera- 
peutic resources. My own practice is to, early or in anticipa- 
tion, give a saline cathartic, the action of which may be expedited 
by a stimulating enema; follow with a minute, or small, dose of 
morphia, hypodermically, and one or two cups of coffee; later 
give ten grains of trional, and an additional five grains if not 
asleep in an hour. 



PNEUMONIA 527 

In these cases you will often find evidences of intestinal putre- 
faction, and for this reason there should be given, in addition 
to the saline, some intestinal antiseptic, as, e. g., salol in small 
doses. In some of these cases, happily rare, there occurs, late, 
an uncontrollable, fetid diarrhea, which may become involun- 
tary and usually ends with the patient's death. The sudden 
onset of this diarrhea is often unexpected, although it is only Gastro-intesti- 
the culmination of an intestinal sepsis which could have been n trac * 
readily detected, and probably corrected, if it had been looked 
for. In my opinion no case of pneumonia is properly managed 
in which careful and frequent investigations of the functional 
activity of the gastro-intestinal canal are ndt made. In these 
•cases the urinary sulphates, and indican, are always increased, 
sometimes to an enormous extent. Prophylactic management 
should be the rule; when recognized energetic treatment should 
be promptly instituted. Delirium 

In another class of cases there occurs, after the height of the 
attack has been reached, a delirium which gradually increases 
in intensity, which also depends upon toxemia, although it is 
quite clear that the character of the toxemia is fundamentally 
•different in the two classes of cases; the management should be 
much the same. 

In these cases of delirium I have had some excellent results 
from free bleeding, followed by normal salt solution by the 
mouth — in the form of weak broths — by the rectum, or by hypo- 
dermoclysis. Ordinarily I attempt to anticipate the advent of 
the condition with one or two large doses — thirty to sixty drops — 
of tincture of digitalis. 

The victim of chronic alcoholism who harbors the pneu- Alcoholism 
mococcus in his upper respiratory tract is frequently attacked by 
pneumonia. Such patients often have, early, that peculiar form 
•of delirium known as delirium tremens. This condition, in pneu- 
monia, is one of great gravity, and demands most considerate 
care and mature judgment. The patient should be constantly 
watched, because he almost always imagines he is beset and pur- 
sued by imminent dangers and cunning enemies and he often 
seizes the first opportunity to escape. He will usually require 
restraint, and this may be given by the nurse in some cases; in 
others he may be restrained by securely fastening the bed cov- 
erings to the sides of the mattress; in some others mechanical 
restraint will be found necessary, and is the most humane. Digi- 
talis, in large doses, I always use. To procure sleep, chloral, care- 
fully administered, is probably the safest hypnotic. My prac- 
tice is to give fifteen grains the first dose, followed by seven and 



528 



PNEUMONIA 



Intestinal 

paresis 



Pulmonary 
edema 



Cardiac failure 



one-half grains every half hour until the patient is asleep. At 
the same time give one-half to one pint of hot milk, and if pos- 
sible, an enema of one-half to one pint of normal salt solution. 
With evidences of collapse give aromatic spirits of ammonia by 
the mouth, the previously advised camphor solution by deep in- 
jection, strychnia and one or two minute doses of morphia hypo- 
dermically. 

In some cases, late, there gradually — rarely suddenly — de- 
velops an intestinal paresis, with abdominal distention and in- 
ability to pass flatus. This denotes a very dangerous, but not 
necessarily hopeless, state. In such cases you should be alert in 
your observations and ready in the application of proper reme- 
dies. Give the stimulating enema of glycerine, sulphate of mag- 
nesium and water heretofore advised, and make use of the rectal 
tube as often as required to stimulate intestinal peristalsis and 
relieve the canal from accumulated gases. Give one-twentieth 
to one-thirtieth grain of strychnia, hypodermically, every two to 
four hours; give digitalis and caffeine in large doses, provided 
they can be absorbed; give by deep injection, a hypodermic 
syringeful of the camphor solution which you have already had 
on hand for such an emergency; early it will be well to bleed 
and do a hypodermoclysis. 

Pulmonary edema is an occasional event which, notwithstand- 
ing its very serious nature, may appear early enough to permit 
of prompt relief. Let me ask you to recognize it promptly. At 
the very beginning raise the foot of the bed as heretofore di- 
rected, in order that the serum may flow, uninterruptedly, out of 
the bronchi and alveoli ; give one-twelfth grain morphia, one one- 
hundred-and-fiftieth grain atropia and one-thirtieth grain strych- 
nia, hypodermically; give by deep injection the camphor solu- 
tion ; give by the mouth a large dose of digitalis ; give the stimu- 
lating enema. Repeat, with proper modifications, as required. 
Energetic stimulation of the capillaries and arterioles by fre- 
quent hypodermics of adrenalin, in 1 to 10,000 solution may be 
required. 

Late the appearance of profuse, probably cool, perspiration 
is an ominous, but not altogether hopeless, symptom. The con- 
dition is probably akin to that of pulmonary edema and requires 
a prompt appeal to a similar line of management. 

Cardiac failure, which is not a simple but is a highly com- 
pound and complex condition, is the marked feature of nearly 
all fatal cases. The foundation for this unfortunate condition 
is laid at the very beginning of the attack, the entering wedge 
being the vaso-motor paresis which speedily transfers a great 
excess of blood from the arterial to the venous side of the circu- 



PNEUMONIA 529 

latory tree. The immediate consequence is a loss of cardiac bal- 
ance, the heart contracting forcibly against an increased resist- 
ance on the one side, and a diminished resistance upon the other. 
It is probable that it is the latter of these, the endless over- 
reaching which is so tiresome to any muscle, which is most detri- 
mental. This loss of equilibrium, and its consequences, steadily 
increases in degree until in many, if not the majority, of cases 
it becomes grave, and in a very large proportion acute — and 
deadly. To the physician, and to the patient if he were aware of 
the fact, the most hopeful feature in these cases is the assurance 
that if the state of danger can be carried along a short time the 
period of stress may be tided over, with timely and spontaneous 
relief appearing at the crisis — convalescence following. I am 
quite sure that one of the questions which the conscientious and 
observing physician oftenest asks himself is, What can T do to 
minimize and relieve this deplorable condition? I will advise 
that you keep constantly in mind the contingencies along these 
lines and be keenly alert in the detection of early evidences of 
serious circulatory embarrassment. From an early period make 
use of the measures heretofore advised for the purpose of wash- 
ing the blood ; remove some of the toxins and dilute the remain- 
der; stimulate the nervous reflexes, thereby keying up the cap- 
illaries and arterioles. In the presence of a late acute condition 
of this kind all these measures should be applied with redoubled 
earnestness; at this time we may find that the removal of from 
twelve to twenty ounces of blood will turn the scale toward safety 
and recovery. 

Let us now shortly consider some of the more important com- complications 
plications which may arise during an attack of pneumonia. 
Pleurisy with serous effusion rarely demands active treatment; 
when it does the liquid should be withdrawn, under the strictest 
aseptic precautions. Do not be disappointed, however, if the 
effusion quickly reappears, for this it usually does, until after 
the lapse of several weeks, when it disappears spontaneously. 
Purulent effusion — empyema — may be an early feature, al- 
though it is oftenest recognized after an initial defervescence, 
and is often confounded with "delayed resolution." In all cases 
in which defervescence is unduly delayed, or in which the fever 
returns, I am led, by my observations, to explore with the utmost 
thoroughness the pleural cavity and the interlobar spaces for the 
presence of pus. When found prompt and efficient surgical 
measures of relief must be given. 

Pericarditis with embarrassing effusion should be promptly 
discovered and relieved by aspiration, with later incision and 
drainage if required. Endocarditis, usually ulcerative, occurs 



530 PNEUMONIA 

sufficiently often to be carefully looked for in all cases. Unfor- 
tunately it is not always detectable; but in any case with pro- 
longed and undue weakness, possibly with slight and irregular 
fever, the question should be given especial consideration ; if any 
doubt exists as to the diagnosis you should act as if it were 
clearly present. When detected the patient should be kept in 
bed, in the recumbent posture and with absolute rest, for at least 
six weeks. The rest should be so profound that the patient 
should make no voluntary movements — not even turning in bed, 
raising his head, etc. 

Arthritis, suppurative peritonitis, etc., require early — con- 
servative — surgical treatment. 

The line between impending and beginning death is an indis- 
tinct, nevertheless a most important, one. Threatened, or im- 
pending, death may sometimes be averted by the masterly em- 
ployment of the measures heretofore mentioned, and others, but 
this is probably impossible in the case of beginning death. Here, 
-as a rule, the respiratory reflexes are weakened in proportion 
to the danger. Now a dyspnea which is readily recognized by 
the observer, but which is not appreciated by the patient, is of 
grave augury, and when this is accompanied by a rising and 
falling of the trachea, and a non-obtrusive clicking noise with 
respiration, and which returns almost immediately after cough- 
ing, the patient has, in my experience, invariably died. So far 
as I am aware this symptom antedates all others which denote 
the approach of death. 

On the other hand when, late in the attack, the patient awak- 
ens from sleep and sneezes, or yawns, or stretches, his safety is 
assured. 

In conclusion: — The treatment of pneumonia may be fault- 
lessly exemplary; it may be carelessly useless and harmless; it 
may be reprehensibly pernicious. The fundamental principles 
-of proper management may be stated, analyzed and formulated, 
but their application to meet the exigencies and requirements of 
the individual patient is an art which can not be transferred from 
one physician to another. Satisfactory proficiency in this art 
can be attained only by those who add to native capacity a keen 
perception of pertinent facts, close study of the problem and 
years of observant practice. Failure is usually traceable to in- 
herent incapacity, paucity of necessary knowledge and restricted 
-experience. 



TYPHOID FEVEg 531 



TYPHOID FEVER, 



There is no specific treatment for typhoid fever. Injections 
of typhoid bacilli, grown on thymus bouillon and destroyed by 
heating (Frankel), injections of dried bacillus pyocyaneus and 
of various typhoid sera that have been prepared, have so far No -pecific 
failed to exercise any appreciable effect upon the course of 'the 
disease. 

It is not possible to abort or jugulate typhoid fever by the 
use of any remedy given by mouth. Intestinal antiseptics, 
while they may be capable in the test tube of holding 
the development of typhoid bacilli in check and if 
used in sufficiently strong concentrations to destroy them, intestinal 
could not exercise this effect in the living without serious detri- antiseptics 
ment to the patient. The use of intestinal antiseptics cannot be 
condemned as useless, however, in typhoid fever, and some 
clinicians claim that they are capable of favorably modifying 
the bacterial flora of the intestine and hence forestalling or check- 
ing to some extent mixed infection and auto-toxemia. The differ- 
ent intestinal antiseptics have been fully discussed in previous 
sections (see page 206 and page 416). They are incapable of cur- 
tailing the duration of the disease and I consider their efficacy 
as quite problematical. 

Of all intestinal antiseptics calomel, if given early in the dis- 
ease, is the most useful one, and it seems to exercise a favor- 
able effect in some cases upon the development of the local lesions 
in the intestine. It is best to give calomel at once in two or three Calomel 
doses of four or five grains. Later in the disease calomel is 
rarely indicated, excepting possibly in severe cases of meteorism 
in which small (one-quarter or one-half grain) doses, given two 
or three times a day, are useful. Yeast is also used extensively 
to modify the intestinal flora, and the results occasionally ob- Yeast 
served from the use of this remedy are sufficiently encouraging 
to warrant its employment in typhoid fever. It can certainly 
never do any harm. Yeast, in contradistinction to calomel, 
should be given throughout the course of the disease. 

With the exception of remedies that are occasionally neces- 
sary to treat cardiac failure, intestinal hemorrhage, profuse 
diarrhea, distressing cerebral symptoms, etc., drugs altogether 
have a very subordinate place in the treatment of typhoid fever. 
Now and then it becomes necessary to use antipyretics in 
those cases in which the fever is very high and does not Antl Py retics 
yield promptly to hydrotherapeutic means, or in which the pa- 
tients bitterly object to the use of hydrotherapeutic measures, 



532 ' TYPHOID FEVER 

■ so that an attempt must be made to relieve them for a time 
of the necessity of being bathed or sponged. Judiciously given 
certain antipyretics reduce the blood temperature, quiet the 
heart, free the sensorium, promote sleep, encourage the appetite 
and often increase the patient's comfort. Only two antipyretics 
can be considered safe, namely, quinine and lactophenin. Anti- 
pyrin, acetanilid, phenacetin are generally dangerous in typhoid 
fever, for if given in doses sufficiently large to reduce the tem- 
perature appreciably they increase the stupor and depression, re- 
duce the flow of urine, weaken the myocardium and often pro- 
duce chills, sweats, cyanosis and collapse. 

Lactophenin Lactophenin, however, is the one phenacetin derivative that, 

in my experience, can be safely used in typhoid. It should be 
given in doses of ten to fifteen grains four or five times in the 
twenty-four hours. It generally produces a drop of two or three 
degrees in the temperature, and induces sleep and euphoria. 

Quinine The best and the safest antipyretic drug of all is quinine. It 

should be given in the dose of fifteen to forty grains in two or 
three divided doses inside of two hours in the evening every other 
day. Within ten or twelve hours a temperature drop of two or 
three degrees' is usually brought about, so that the temperature on 
the next morning is low. During the course of the day the tem- 
perature slowly rises again, but rarely reaches the same height 
that it would have reached if quinine had not been administered 
the evening before. During the quinine days bathing or spong- 
ing should not be instituted. Occasionally disagreeable, but not 
dangerous, symptoms, as buzzing in the ears, tremor, light- 
headedness, and diarrhea may follow the use of quinine. 

Diet The most important elements in the treatment of typhoid 

fever are the diet and hydrotherapy. The diet should be exclu- 
sively liquid during the fever period, and for a week or ten 
days thereafter. The food should be digestible (see page 347), 
non-irritating to the bowel and it should leave a small residue. 

Milk The ideal food in typhoid fever is milk. It should be given 

in quantities of from two to three quarts a day, preferably 
diluted with water or lime water. In placing a typhoid fever 
patient upon a milk diet, the stools should be examined every 
day for curds, and if the latter appear the milk ration should 
be reduced, -or, if necessary, stopped altogether. Some people 
have a marked aversion to milk. In such cases it is bad practice 
to force milk drinking and it is well to realize that the patient 
can very adequately be nourished for several weeks on a liquid 
diet if no milk is given or some of the other foods, to be pres- 
ently described, are administered in its stead. An attempt 



TYPHOID FEVER 



533 



should, nevertheless, be made to accustom the patient to the use 
of milk or milk foods. If the milk is given very cold in small quan- 
tities and at frequent intervals,, many patients gradually learn 
to relish and to tolerate it. If this can be accomplished within 
a few days, then the amount of milk given at each feeding may 
be increased and the intervals of feeding shortened, so that in 
this way the full quantity may be ultimately administered. Oc- 
casionally the addition of a little coffee, or brandy, or egg to 
the milk renders it more palatable so that the patients can take 
it in this form. 

In addition to milk diet and substitutes for milk, the pa- Gruels 
tients may have gruels made from barley, arrowroot, rice and 
oatmeal, that are carefully strained and to which are added a 
little butter and salt. A little yolk of egg,- or some meat juice, Eggs 
meat broth or meat extract as a flavor, or beef broth with egg Meat broth 
to which is added flour made of wheat, rice, sago or barley, may 
be given. 

One of the most useful preparations is raw meat juice made Raw meat juice 
by expressing in a meat press beef that has been cut into small 
pieces. The juice is of a light-red color and possesses a slight acid 
reaction. As it readily decomposes it should be kept on ice and 
should be prepared fresh every twenty-four hours. The patient 
should receive from 100 to 200 grammes of this meat juice in 
the twenty-four hours. In order to administer this amount, one 
or two tablespoonfuls of the meat juice should be added to the 
ordinary broth, or to some of the milk preparations enumerated 
above. In addition a tablespoonful of the juice should be gh en 
every two or three hours throughout the day. Some patients 
have a great aversion to the meat juice and dislike its taste and 
odor. Here a peppermint lozenge chewed before the meat juice 
is taken often overcomes this repulsion. 

Another very elegant preparation of meat juice that is par- Frozen meat 
ticularly useful in cases that cannot take the liquid preparation, 
and in patients who suffer from severe vomiting, is frozen meat 
juice. Ziemssen recommends the following method of preparing 
it: 500 cc. of fresh meat juice are sweetened with 250 grammes 
of sugar and flavored with 20 cc. of lemon juice and about 20 
cc. of brandy ; to this mixture are added three yolks of egg and 
a little vanilla. It is then frozen in an ice cream freezer. 

Meat jelly (see also page 37) made from chicken, veal or beef is Meat j^lly 
also a very grateful food for some people. The meat is chopped 
up fine, heated in a casserole to boiling temperature without the 
addition of any water. The juice solidifies as soon as it cools off 
and can be added to ordinary meat broth and to milk foods'! It 



534 



TYPHOID FEVER 



is useful more as a flavor than as a food. "Wine jellies or other 
gelatine preparations are a very welcome addition to the diet. 

Liquids The quantity of fluid nourishment and of water need not be 

limited. Broadly speaking the more liquid a typhoid patient 
will take, the better. One should never wait until the patient 
manifests a desire to drink water or to. take liquid food, but small 
quantities of liquid should be offered at frequent intervals, not 
to exceed half an hour, throughout the day, and, if the patient 
is awake, also during the night. 

Alcohol Alcohol is a very useful food and stimulant and may with- 

out detriment be given throughout the course of the disease. It 
may be administered in the form of dilute white wine or brandy 
in water, or in the form of the very useful Stokes' brandy-egg 
mixture consisting of 50 cc. of brandy, two yolks of egg, 150 cc. 
cinnamon water and 25 cc. of simple syrup. This quantity 
should be administered in divided doses in the course of twenty- 
four hours. Many patients enjoy hot tea with a little rum or 
a little champagne. Claret or burgundy should not be given cold, 
because a cold alcoholic solution of tannin is irritating to the 
walls of the stomach and bowel. Given hot, however, burgundy 
flavored with sugar, cinnamon and cloves is a very useful stim- 
ulant and astringent and acts particularly well in meteorism ; 250 
to 500 cc. of this drink may safely be given. Lemonade is a very 
useful beverage, especially as the ethereal oil of the lemon stim- 
ulates the flow of saliva and hence keeps the mouth moist. 

Hydrotherapy Hydrotherapy occupies the most important place in the 

treatment of typhoid fever. Water treatment acts favorably not 
only by reducing the temperature but by exciting the nerves 
of the circulatory apparatus, by its action on the vaso-motor sys- 
tem and by its stimulating effect upon the nervous elements sup- 
plying the various organs. It counteracts functional inadequacy 
and parenchymatous changes in many important organs that are 
commonly affected in typhoid fever. The vaso-motor effect is 
particularly important in all infectious diseases: in typhoid 
fever especially as there is always danger of paralysis of the vaso- 
motor centres. Upon the respiratory centres cold hydrothera- 
peutic measures also exercise a very pronounced effect. By 
means of cold applied to the surfaces of the body deeper breath- 
ing is generally produced and as the heart's action is at the same 
time strengthened, the occurrence of bronchitis and pneumonia 
is effectually prevented. Upon the nervous system hydrotherapy 
also has a most pronounced influence. It is the sovereign remedy 
to rouse patients from the stupor they are apt to lapse into in 
typhoid fever. Hydrotherapy judiciously applied improves the 
appetite, promotes sleep and by keeping the patient aroused and 



TYPHOID FEVER 



535 



active renders his care easier, prevents decubitus and, to a certain 
extent, the development of disagreeable mouth complications 
when the stuporous, somnolent patients no longer voluntarily 
perform swallowing or chewing movements. 

The following general rules in regard to the application of General rules 
hydrotherapeutic means may be formulated : The thermic stim- 
ulus should be as energetic as the patient can tolerate and it 
should, in every case, be reinforced by producing artificial dila- 
tation of the cutaneous vessels by friction of the patient's skin 
while he is immersed in the water. It is good practice to begin 
with mild hydrotherapeutic means and then gradually to adopt 
more severe ones or not according to the individual reaction of 
the patient. Many methods of hydrotherapeutic treatment in 
infectious diseases can be adopted. 

In hospital practice the severer methods are commonly em- Brand treat- 
ployed, especially the orthodox Brand treatment, which con- men 
sists in giving the patient a full bath of 70° F. to 64° F. for 
ten minutes as soon as the temperature rises over 103^4° F., 
five to six of such baths being given a day. In private prac- 
tice this method is more difficult to carry out because it requires 
a movable bath tub or a bath tub kept permanently in the pa- 
tient's room, and also requires one or two assistants to trans- 
port the patient into the bath and back into bed again. In addi- 
tion the patients generally bitterly complain of this treatment 
and object to it seriously. Moreover, it is questionable whether 
this severe method possesses sufficient advantages over milder 
ones to warrant its employment. The fear of the patient and his 
opposition to these cold baths are not without detriment on ac- 
count of the nervous excitement this opposition produces ; hence, 
if the full bath plan is to be adopted at all it is usually better 
to use water of moderately high temperatures in the beginning. 
Here it is necessary to strictly individualize before instituting a 
routine bath treatment and the individual reaction of the patient 
to the different temperatures should always first be determined. 
One can begin safely with immersion of the patient in water of 
89° F. to 82° F. (32 to 28° C.) and then gradually cool the bath 
water off to 75° to 68° F. (24 to 20° C). If the patient is very 
anemic or very sensitive, or if symptoms of collapse appear, then 
the temperature should not be allowed to go below this point. If 
the patient develops a chill while in the bath he should be imme- 
diately removed. No attempt should ever be made to reduce the 
temperature below normal, in fact, it is always a safe plan to 
limit the reduction of the temperature to about two or three de- 
grees Fahrenheit, the patient remaining in the bath for fifteen 



536 TYPHOID FEVER 

to thirty minutes, not longer. As soon as the patient is placed 
into the water energetic friction of the surfaces of the body 
should be performed, and this should be kept up during the 
whole time that the patient is in the water. If there is much 
respiratory difficulty, the patient suffering from bronchitis or 
pneumonic symptoms, then cold water should be poured over 
the head, neck, chest and back at the end of the bath. In this 
way a few deep respirations are stimulated that, as stated above, 
act beneficially in counteracting the congestion in the respiratory 
apparatus. 

The drop of temperature rarely persists for longer than three 
hours after the bath, consequently, in order to produce a perma- 
nent antipyretic effect it becomes necessary to give five or six of 
such baths during the twenty-four hours. In this way the aver- 
age temperature can effectually be kept down two or three de- 
grees. 

On removal from the bath the patient may either be wrapped, 
without drying, in a linen sheet and covered with a thin woolen 
blanket, and after a rest of fifteen to twenty minutes, the sur- 
faces of the body may be dried and a dry nightshirt put on. If the 
temperature has been reduced over two or three degrees, Fahren- 
heit, however, it is usually better to rapidly dry the patient and 
to wrap him in a warmed linen sheet. Both before and after the 
bath the patient may to advantage receive a stimulant, consist- 
ing of a little wine or a few teaspoonfuls of hot coffee. That the 
patient should be carefully transported into and removed from 
the bath need hardly be emphasized. Contra-indications to the 
bath treatment are hemorrhage, perforation, peritonitis or im- 
pending heart failure and collapse. 

"Wet pack In private practice, and particularly among the poorer 

classes who cannot secure adequate bathing facilities, the wet 
pack may take the place of the full bath. This method of water 
treatment does not exercise so pronounced an antipyretic effect, 
as the full bath, but acts very beneficially nevertheless. The wet 
pack is best administered as follows : A large linen sheet is 
wrung out of water of 50 to 54° F. (10 to 12° C), the patient 
rapidly wrapped into the sheet and allowed to remain in this 
packing for six to ten minutes. At the end of this period a 
second wet pack is applied and this procedure repeated three or 
four times. It is good practice to leave the patient in the last 
pack for fifteen to twenty minutes. The most practical method 
of carrying out this plan is to have two beds and to transport 
the patient from one wet pack into the other. 

Sponging A third method, and one that may be applied as a routine 



TYPHOID FEVER 537 

measure in every case of typhoid fever, immaterial whether the 
temperature rises above 102% °F. (39° C.) or not, is sponging 
of the surfaces of the body with cold water of 50 to 54° F. (10 
to 12° C.) or with ice water to which may be added a little vine- 
gar or alcohol. By carefully going over the whole body with a 
cold sponge every two or three hours the temperature can always 
be somewhat reduced, and, above all, a beneficial stimulating 
effect can be obtained. After the sponging the patient should, 
of course, be carefully dried and covered with a linen sheet and 
a thin woolen blanket. 

It is useless to designate the many other methods of hydro- 
therapeutic treatment by means of half-baths, partial packs, etc., 
that have been described. The lukewarm full bath gradually 
cooled and combined with friction and cold douches, the wet 
pack, and sponging, always suffice to produce the desired result. 

COMPLICATIONS. 

Certain complications of typhoid fever require particular Nervous com- 
discussion. About the nervous system the symptoms may either 
be those of depression or of excitement. The stupor and somno- 
lence are best combated by the use of cold douches given in a 
lukewarm bath and the application of an ice bag or a Leiter coil 
to the head either permanently or interruptedly. The symptoms 
of excitement and meningeal symptoms manifesting themselves 
by severe headache, delirium, restlessness, insomnia, etc., are 
best treated by lukewarm baths or, in extreme cases, by hot 
baths. While the patient is immersed in the warm water, an ice 
bag or a Leiter coil should always be applied to the head. In 
cases of insomnia or headache that do not yield readily to these 
simple hydrotherapeutic means, trional, sulphonal or lactophenin 
may occasionally have to be given. Opium and morphine, how- 
ever, preferably the latter given hypodermically in doses not to 
exceed one-fourth of a grain, two or three times a day, are the 
best remedies. 

One of the chief dangers in typhoid fever is circulatory fail- Circulatory 
ure, either gradually progressive or sudden. The tendency to 
heart failure, manifesting itself by a rapid small pulse, low blood 
pressure, a cool skin, a pale face and later cyanosis, must be 
energetically counteracted by various remedies. Best of all in 
the gradually developing cases is alcohol administered in the 
form of brandy, hot claret with spices or, better yet, champagne, 
the latter to be given in liberal doses. Strychnine, too, given in 
doses of one-thirtieth of a grain every three or four hours is a 
useful remedy in this condition. Digitalis should be given with 
great care and preferably not at all on account of the danger of 
myocarditis (see page 30). In sudden heart failure, camphor is 



538 



TYPHOID FEVER 



the sovereign remedy. It may either be given in ten per cent, 
ethereal solution in the dose of ten to twenty drops hypoder-' 
mically, and frequently repeated until the heart's action im- 
proves, or in the form of a ten or twenty per cent, solution in 
sterile olive oil, a syringe full of this solution to be injected 
hypodermically every one and one-half to two hours. Adrenalin 
chloride, in ten per cent, solution, twenty to thirty drops hypo^ 
dermically, also occasionally aids in combating sudden heart 
failure. The ice bag over the heart, or a Leiter coil, preferably 
applied intermittently, is also useful in these cases. 

Diarrhea Certain symptoms about the intestinal tract may require spe- 

cial attention, particularly diarrhea and meteorism. If the pa- 
tient has four Or five liquid stools a day this mild form of diar- 
rhea requires no special treatment, but if more than five move- 
ments in the day are deposited, then the frequency of the mo- 
tions should be reduced. The best remedy is opium, which 
should by preference be given per rectum in a starch enema as 
follows : Ten to fifteen drops of the tincture of opium dissolved 
in two ounces of starch water (one tablespoonful of starch to 
eight ounces of water) should be injected every two or three 
hours through a high rectal tube until the diarrhea is checked. 
It is best to refrain from the administration of opium or tannin 
by mouth on account of the irritating effects these remedies 
exercise upon the gastric mucosa. Bismuth subnitrate in ten to 
fifteen grain doses, given every two or three hours, may, how- 
ever, to advantage be combined with the rectal opium treatment. 

Meteorism Excessive meteorism (see also page 461) is a very distressing 

symptom and one that it is difficult to treat. The expulsion of 
the gas may' frequently be promoted by inserting a high rectal 
tube and in this way preventing the contraction of the sphinc- 
ter. A Leiter coil or an ice bag should be applied to the abdo- 
men in some cases while in others hot applications, especially 
flannel cloths wrung out of hot water to which a few drops of 
turpentine are added, are more grateful to the patient and more 
effective in overcoming abdominal distention with gas. Enemas 
of warm physiological salt solution, containing from three to 
five drops of turpentine to the quart, may be injected and drop 
doses of turpentine, preferably in a little milk, may also be 
given by mouth. 

Constipation Constipation is usually a negligible symptom unless it per- 

sists for more than two or three days. It does not often super- 
vene if the initial large dose of calomel mentioned above is 
given. It is always best to attempt evacuation of the bowels by 
soap suds or turpentine enemata. If any laxative is given it 



DIPHTHERIA 539 

should be a saline, i. e., a Seidlitz powder, magnesium or sodium 
sulphate. 

Hemorrhage from the bowel (see also page 439) requires ener- Hemorrhage 
getic treatment. The patient should be put completely at rest, 
bathing or other hydrotherapeutic means stopped, and for 
twenty-four hours all food and drink withheld. Later, a little 
cold milk, ice pills to allay the thirst or a little bouillon, broth or 
dilute wine may be given. Ice bags should be applied to the, 
abdomen. Styptics, given by mouth or hypodermically, or by 
rectum, are not of much value in controlling the bowel hem- 
orrhage in typhoid fever. The different hemostatic drugs have 
been discussed on pages 439 and 440. 

Perforation of the bowel, with or without peritonitis, is usu- Perforation 
ally a fatal complication. Every effort should, in typhoid fever, 
be directed towards preventing this accident by careful regula- 
tion of the diet, rest, avoidance of straining and coughing efforts, 
sudden movements, etc. After perforation has once occurred 
there is nothing to do excepting to keep the patient perfectly 
quiet, preferably with the aid of hypodermic morphine injec- 
tions. In view of our helplessness from a medical standpoint to 
treat perforation, laparotomy and mechanical closure of the 
rupture should always be considered, especially if the accident 
is discovered early before symptoms of diffuse peritonitis have 
made their appearance. This operation has frequently been per- 
formed during late years and the results obtained in skillful 
hands have been so favorable as to warrant the adoption of this 
radical procedure in most cases. For the treatment of acute 
diffuse peritonitis I refer to the section on this disease (page 
468). 

Decubitus is prevented by rigid cleanliness, by keeping the Decubitus 
skin dry, by ordering the patients to frequently change their 
position. Upon the appearance of a bed-sore the air cushion 
should be used, the parts frequently bathed with alcohol, care- stomatitis 
fully dried and dressed with boric acid powder. The treatment 
and prevention of stomatitis has already been discussed on page 
259. 

The treatment of recurrences is in all essentials the same as Recurrences 
that of the original attack. Here again hydrotherapeutic meas- 
ures and the diet are the dominating features of the treatment. 

DIPHTHERIA. 

The injection of antitoxic serum has rendered the treatment Antitoxin 
of diphtheria relatively simple. There is scarcely any need, as 
a rule, for the administration of internal medicines, excepting 



540 



DIPHTHERIA 



Hypothetical 
dangers of 
antitoxin 



Method of ad- 
ministration 



to treat the complications and sequelae of diphtheria, and the 
latter, provided antitoxin is given early in the disease and in 
the proper' dosage, are exceedingly rare. 

The local treatment, that formerly occupied so large a place 
in the management of diphtheria cases, has become almost super- 
fluous and intubation and tracheotomy are performed much less 
frequently now-a-days than formerly when laryngeal and tra- 
cheal diphtheria (croup) were common occurrences. 

There is no longer any doubt that diphtheria antitoxin prop- 
erly administered is the best remedy for the disease. Statistics 
in regard to the mortality under antitoxin treatment, and clin- 
ical studies in regard to the duration and severity of the dis- 
ease under the influence of diphtheria antitoxin, demonstrate 
this conclusively. ' Under this remedy the course of the disease 
is, in a large majority of the cases, markedly modified, the mem- 
brane is loosened and sloughs off much earlier, laryngeal and 
nasal complications are prevented or promptly aborted, the gen- 
eral prostration and malaise are not so marked, and the temper- 
ature does not rise so high and returns to normal sooner than 
if the patient had been treated without antitoxin. 

It has been claimed that antitoxin may cause heart failure, 
paralysis, albuminuria, nephritis and other complications. It 
is true that cardiac failure and paralysis occur as frequently in 
diphtheria cases that are treated with serum as in cases that 
are treated without serum ; in fact, some statistics show that more 
cases of diphtheria (that survive) develop signs of heart intoxi- 
cation when treated with antitoxin than without; but one is 
justified in assuming that these cases would have died had they 
not received the benefits of antitoxin treatment, so that the fig- 
ures revealed by the statistics in regard to the occurrence of 
cardiac complications are exceedingly misleading and in no 
sense justify the conclusion that the serum produced the phe- 
nomena about the heart and the peripheral nerves. 

The albuminuria, renal complications, urticaria, arthritis, 
etc., that sometimes follow the administration of antitoxin are 
due to the injection of large quantities of a foreign serum and 
not to the antitoxin itself ; this is borne out by the fact that now- 
adays when small quantities of concentrated serum are used 
instead of the large quantities of dilute serum that were form- 
erly employed, these sequehe, notably, the albuminuria and the 
skin eruptions, are exceedingly rare. 

The injection of antitoxin should be made into the subcuta- 
neous tissues and not into the muscles nor into any of the super- 
ficial cutaneous veins. The best locations for the injection are 



DIPHTHERIA 541 

the external surfaces of the thigh, the abdominal parietes and 
the upper pectoral region. Nowadays a sterile syringe of proper 
size and construction is furnished with each package of diph- 
theria antitoxin. If the syringe should become broken, or if the 
antitoxin is purchased without the syringe, then a large Pravaz 
syringe should be carefully sterilized and used for the injection. 
That the field of operation and the hands of the physician should 
be rendered aseptic by thorough scrubbing with soap and water 
and bathing with bichloride solution, alcohol and ether need 
hardly be emphasized. 

The ordinary dose for children under ten years is five hun- 
dred units, if given on the first day; a thousand units if given Dosage 
after the second day. In children over ten years, and in adults, 
a thousand units should be given at once and, if the symptoms 
are not very much improved in twenty- four hours, a second thou- 
sand units shoulot'be given and, if necessary, a third thousand at 
the expiration of another twenty-four hours. If the case is 
seen in an advanced stage, i. e., on the second or third day of 
the disease, or if signs of laryngeal involvement have made their 
appearance, then the first injection of a thousand units should 
be followed in six or twelve hours, according to the reaction of 
the patient, by a second thousand units, and in another six or 
twelve hours by a third injection of a thousand units. It will 
hardly ever become necessary to give more than three thousand 
units, for after this amount of antitoxin has been injected, and 
the patient fails to show marked improvement, further doses of 
antitoxin will be without effect. 

The local treatment under antitoxin, as stated above, is very Local treat- 
simple. Meddlesome spraying and swabbing of the throat is to men t 
be condemned, especially in children, for the excitement incident 
to the local treatment, and the struggles of the child, are decidedly 
detrimental ; moreover, vigorous swabbing of the affected area is 
apt to produce local trauma and to throw the doors wide open 
for the invasion of septic germs and secondary involvement of 
various internal organs. Vigorous local treatment in the nose 
is especially to be condemned on account of the danger of pro- 
ducing middle ear infections. Besides, the escharotic effect of 
strong remedies applied directly to the diphtheritic area is apt 
to aid the absorption of the diphtheritic poison. Drugs strong 
enough to kill diphtheria bacilli are very apt to produce medic- 
inal poisoning from the quantities of the drugs that are swal- 
lowed, or that are absorbed through the diphtheritic area. It is 
doubtful, moreover, whether strong germicides like sublimate, 
carbolic acid, ferric chloride, silver, nitrate, lactic acid, creolin 



542 



DIPHTHERIA 



Swabs and 
sprays 



and others applied locally exercise any very strong bactericide 
effect, for the bacteria are usually protected from the action of 
the drugs by mucus and by lymph and albuminous fluids that 
readily coagulate when touched" with these different remedies ; 
the contact with the germicides, moreover, is really too short to 
be effective. 

Occasionally if there is much fetor, or if many pus germs 
are present, the throat may be swabbed or sprayed gently with 
a two to three per cent, solution of chlorate of potash ; or with a 
one to ten per cent, solution of iodoform in glycerin; or with 
a mixture of equal parts of peroxide of hydrogen and water (if 
the latter drug is used, the lips, especially in children, should be 
protected with vaselin) ; or insufflations of iodoform mixed with 
sugar of milk in the proportion of one to three, or with bicar- 
bonate of soda in the same proportion, may be employed. The 
chlorate of potash solution mentioned above may also be used as 
a gargle. A very popular solution for local application is 
Loeffler's, consisting of: 



5 



Menthol, 

Toluol, 

Alcohol, 

Liq. ferri sesq., 



10 gm. 

36 cc. 

60 cc. 

4 cc. 



irrigation of Best of all are irrigations of the throat every two or three 

nose and mouth h ours w ith copious quantities of a one to two per cent, boric acid 
solution, or with a one-half to two pro mille salicylic acid solu- 
tion. The child's head should be held forward over a bowl and 
from one to two quarts of the solutions allowed to run into the 
mouth from an irrigator hanging four to six feet above the 
child's head; if there is little membrane in the mouth, then the 
irrigation may be performed through the nose, although this 
procedure is not without danger on account of the risk of pro- 
ducing middle ear involvement. 

Cold applied either externally or internally is generally very 
grateful and aids in allaying congestion and inflammation. The 
patients may either swallow ice pills at frequent intervals or 
may suck ice-cold beverages in small quantities through a straw. 
Externally, a Leiter coil (see index) is of the greatest benefit, 
or a permanent ice poultice may be used to advantage. 

Internally medicines are not indicated. Antipyretics espe- 
cially are unnecessary and usually dangerous to the heart. In 
some clinics the use of mercury or of silver administered 



Cold applica- 
tions 



Drugs by 
mouth and in 
unction 



DIPHTHERIA 543 

by inunction is popular and sufficiently favorable results 
.are reported from this practice, especially before the antitoxin 
treatment was universally employed, to warrant the occasional 
use of this method, either as an adjuvant to the antitoxin treat- 
ment or as a substitute for it if antitoxin cannot be readily 
procured. 

From fifteen to thirty grains (1 to 2 gm.) of Unguentum 
Hydrargyri are rubbed into the skin in different parts of the 
body each day, or fifteen to forty-five grains of the unguentum 
Crede are administered in the same way by inunction. The dose 
of either ointment may be increased somewhat on the third or 
fourth day. Inunctions should not be made about the skin of 
the neck, but in other parts of the body. 

Hydrotherapeutic means have a very limited field of employ- Hydrotherapy 
ment in the treatment of diphtheria. Cold hydrotherapeutic 
measures, instituted for the purpose of reducing the tempera- 
ture, are to be condemned as superfluous if the diphtheria anti- 
toxin is used, and as dangerous, Especially to the heart, in any Collapse 
case. If the patient goes into collapse from heart failure, then 
immersion in hot water (100°) may be indicated as an emer- 
gency procedure. On being taken from the hot bath the patient 
should be wrapped in blankets and kept perfectly still in bed 
for several hours, while analeptics (see page 32), coffee, cham- 
pagne, whisky, by mouth; ether, camphor, ammonia, caffein, 
hypodermically, may be used. Inasmuch as heart failure is apt 
to occur at almost any time during the course of diphtheria, and 
especially during the convalescent period, analeptic remedies 
should always be kept at hand for emergencies and the attend- 
ants instructed in their use. 

A diphtheria patient should be kept at rest in bed and should Rest 
not be allowed to make any sudden movements or to get up at 
all until the temperature is perfectly normal. The heart should 
be inspected daily and, if necessary, supported with a little wine 
or champagne. The diet should be very nourishing, contain an Diet 
abundance of albuminous food and should be palatable. If the 
patient has much difficulty in swallowing it may become neces- 
sary to administer food either by the rectal route, the stomach 
tube or a nasal catheter. 

Croup, since the introduction of antitoxin, is a rare compli- Croup 
cation. If the membrane forms in the larynx or the trachea, 
then inhalations of equal parts of lime water and distilled water 
through a steam inhaler are usually very grateful to the patient 
and aid considerably in loosening the membrane. Profuse sweat- 
ing produced by pilocarpine hydrochlorid one-twentieth t<> one- 



544 



Intubation 
Tracheotomy 



half grain (0.003 to 0.3 gm.), hypodermically ; by hot, wet packs; 
by the steam tent (see index) or by hot air, are considered 
efficacious in relieving the dyspnea and in promoting loosening 
of the membrane. 

In nearly all cases the administration of antitoxin acts with 
particular efficacy in promoting shedding of the membrane. The 
expulsion of the membrane may further be facilitated by the use 
of emetics, apomorphine, ipecac, tartar emetic (see page 281). 

If despite the administration of antitoxin and the employ- 
ment of steam inhalations, sweating and emetics the membrane 
continues to form or is not loosened and expeiled, then intubation 
or even tracheotomy may have to be performed. Fortunately 
the necessity for this operation is becoming less and less. The 
description of the methods of intubating or tracheotomy does 
not lie within the scope of this book. 



Quinine a 
specific 



Mode of action 



Mode of ad- 
ministration 



Preparations 
of quinine to 
"bo given by 
mouth 

Cuinine hydro- 
chlorid 
sulphate 



MALARIA. 

The employment of quinine as a specific renders the treat- 
ment of malaria exact and simple. Quinine and its salts are 
protoplasmic poisons. They act more strongly, possibly specific- 
ally, upon lower forms of life than on the more highly organized 
cells of the human body ; hence quinine in doses that do no harm 
to the protoplasm proper of the host possesses the power of de- 
stroying unicellular organisms like malaria parasites that in- 
vade it. 

Quinine preparations may be given by mouth, by rectum, hy- 
podermically and intravenously. In the great majority of cases 
the administration by mouth is effective. If much gas- 
tric irritation develops from the administration of quinine by 
mouth, or if it is desired to obtain a somewhat more rapid 
effect, the administration by rectum in clysma or suppository 
may be adopted. If a still more rapid effect is desired the drug 
may be given hypodermically ; and in pernicious forms of malaria 
when the patient is in danger of his life and an immediate re- 
sult is desired, quinine may be injected into the veins. 

Numerous preparations of quinine have been used. For ad- 
ministration by mouth the hydrochlorid of quinine is the best. 
Quinine sulphate is also very useful. The quinine hydrochlorid, 
however, contains percentically more quinine than the sulphate, 
it is also more rapidly absorbed, so that twice to three times as 
much of the sulphate must be given as of the chlorid in order 
to obtain the same effect. 

In very nervous subjects and in individuals in whom the 
administration of quinine exercises an irritating effect upon the 



MALAEIA 545 

nervous system the valerianate or bromid of quinine may be Quinine vale- 
given in place of the chlorid or sulphate. It will rarely be nee-, ^^id 
essary to use these compounds, however, for if it is desired to 
secure a valerianate or bromid effect it is always simpler and 
safer to give the two drugs separately. This is especially true 
as quinine in order to be effective must be given in large doses, 
as will be presently shown, and because this task is rendered 
difficult if the drug is given in chemical combination with sub- 
stances that cannot safely be administered in large quantities. 

A very useful preparation of quinine is euquinine. This Euquinine 
remedy is particularly useful for administration to children, as 
it does not possess the bitter taste nor most of the toxic prop- 
erties of quinine Irydrochlorid or sulphate, while it is quite as 
effective as any of the latter preparations. In giving euquinine 
instead of quinine salts about one-and-a-half parts of euquinine 
should be allowed in place of one part of quinine. 

Quinine hydrochlorid or sulphate are best administered in Administration 
capsule or pill form. It is true that in solution the absorption goiutkm 1 * 
of quinine is very much more rapid, but the bitter taste of such 
solutions, that is only poorly disguised by the administration 
of the drug in syrups or in watery solution flavored by various 
volatile oils or in coffee, is a serious deterrent to its employment 
in liquid form. 

For hypodermic use the acid hydrochlorid of quinine Hypodermic 
(quinine bimuriate) is the best; it should be administered in method 
ten to twenty grain doses dissolved in about 2 to 3 cc. of water. 
The neutral chlorid of quinine is not very soluble in pure water. 
If the solution is prepared with hot water, however, and if a 
little urea is added, the solubility of the quinine chlorid is in- 
creased and the injection is not quite so irritating. 

For rectal use a little opium should be added to the quinine Rectal method 
solution as quinine salts are somewhat irritating to the rectal 
mucosa. The solution may either be made with water or with 
mucilage and one of the following two formulae can be utilized 
for preparing the clysma : 

Quinine hydrochlorid, 2.0 gm. 



Or 



Tincture of opium, 10 drops. 

Water, 100.0 cc. 

Quinine hydrochlorid, 2.5 gm. 

Tincture of opium, 10 drops. 

Mucilage, 40.0 cc. 



546 



Intravenous 
method 



Time to ad- 
minister qui- 
nine 



For intravenous injections an acid solution of quinine can- 
not be used. The solution should be neutral. The best prepa- 
ration is the following, recommended by Bacelli: 



The simple 
intermittent 
type of malaria 



? 



Quinine hydrochloride 
Sodium chloride, 
Distilled water, 



1.0 gm. 

0.075 gm. 

10.0 cc. 



This solution is to be heated to body temperature and trans- 
fused directly into the veins of the fore-arm, as described in the 
Section on Pernicious Anemia, on page 75. The injection of such 
large quantities of quinine intravenously generally produces 
severe symptoms of intoxication, i. e., a bitter taste in the 
mouth, dizziness, tinnitus aurium, cold sweats, some precordial 
distress, palpitation and a feeling of oppression. These symp- 
toms usually disappear promptly in from fifteen minutes to 
half an hour and are usually negligible. If the pulse becomes 
very weak and slow a hypodermic injection of ether, or camphor 
and ether, may be given. 

The treatment of the malarial paroxysms with quinine varies 
somewhat according to the type of malaria. Inasmuch as very 
large doses of quinine are apt to produce a variety of disagree- 
able symptoms as indicated above, it is desirable to produce 
the desired effect with the smallest possible quantity of the drug. 
For this purpose, especially in the simple quotidian type of 
malaria, it is important to administer the quinine in one or two 
relatively small doses at exactly the right time rather than in- 
discriminately throughout the day. 

The rules that should be observed in the treatment of the 
simple intermittent form of malaria are the following : Provided 
the patient has been observed for several days and it is known 
that the type of malaria is of the quotidian variety, or if the 
blood examination reveals this to be the case, then the patient 
should receive fifteen grains of quinine, twice, six and five hours 
before the time when the attack is expected. This therapy some- 
times aborts the attack. In most cases, however, the administra- 
tion of quinine on the first day does not stop the attack. If 
administered at the same time and in the same way on the sec- 
ond day, the attack is, in the great majority of cases, aborted. 
It is best then to continue the administration of thirty grains of 
quinine for two or three days more in the same manner. This 
is particularly necessary if a blood examination is not made and 
the type of malaria positively established, for it is important to 
remember that a daily malarial paroxysm may be due to three 



MALARIA 547 

colonies of quartana, so that here it would be necessary to ad- 
minister the dose of quinine for at least four or six days if the 
parasites are to be destroyed in the amebic stage. 

If the patient is seen for the first time, when the attack To abort an 
is just impending, and if the first attack occurring on the pre- attack * 
ceding day was exceedingly severe, so that it is desirable to 
prevent the occurrence of another attack, then fifteen to forty- 
five grains (1 to 3 gm.) should at once be administered hypo- 
dermically. 

If the patient is seen for the first time during an attack, it No quinine 
is altogether useless to give quinine in the simple intermittent durm £ attac 
form of malaria. 

If the patient is seen after the attack and if the seizure was Quinine treat- 
very severe, and especially if the exact type of the malaria is Stack 
not known, then fifteen to twenty grains (1 to 1% g m -) of 
quinine should be given at once and the same dose repeated on 
the next day about five or six hours before the time of the ex- 
pected paroxysm. 

In atypic intermittent types of malaria and in the sub- Atypic inter- 
continuous pernicious variety no definite rules can be formu- mittent *yP e 
lated in regard to the exact time for administering the quinine. 
A safe rule is to give from ten to fifteen grains (0.6 to 1 gm.) 
of the drug by mouth every four or five hours for several days. 
It will often be found that the type of the disease then changes 
to the simple intermittent variety which should be treated as 
indicated above. 

If one is dealing with the pernicious type of malaria with Pernicious 
severe apoplectic symptoms, or an overwhelming intoxication pro- type 
ducing coma and tetanic convulsions, then quinine in doses of 
fifteen to thirty grains should be given at once and preferably 
by the intravenous method, this dose to be repeated every ten 
or twelve hours on several successive days. 

There are some individuals unfortunately possessing a marked idiosyncrasy 
idiosyncrasy to quinine. They respond to the administra- a f ainst <l ui - 
tion of even small doses of the drug with signs of cerebral con- 
gestion, disturbances of the senses of sight, smell and hearing, 
with nausea and vomiting, severe headache, dizziness, maniacal 
attacks and somnolency. While no case of death from quinine 
administered in therapeutic doses has ever been reported it, 
nevertheless, becomes necessary in such cases to reluctantly 
omit the use of the drug and to attempt the treatment of mala- 
rial paroxysms by some other means. Only in the pernicious 
type should quinine be administered notwithstanding the 
idiosyncrasy of the patient and the disagreeable reaction that 



548 



follows its exhibition, for here the best and most rapidly-acting 
remedy must, by all means, be given in order to save the patient's 
life, and the personal sensations of the individual can there- 
fore in no way be considered. 

Chief among the remedies that can take the place of quinine 
is methylene blue in doses of two to four grains (0.1 to 0.2 
gm.), by mouth; or hypodermically, in five per cent, solution 
Methylene blue in drachm doses. It colors the urine a greenish blue and occa- 
sionally produces strangury and slight gastro-intestinal irri- 
tation. The strangury can usually be counteracted by the addi- 
tion of nux muschata to each capsule of methylene blue, a con- 
venient formula being the following one : 



Remedies to 
replace qui- 
nine 



Mode of action 



Eucalyptus 



Antipyrin 
Carbolic acid 
Acetanilid 
Phenacetin 



Arsenic 



3 



Methylene Blue, 
Nutmeg, 



of each, 0.1 gm. 



M. 



S. Five to six such capsules daily. 

Methylene blue probably acts like quinine by its lethal effect 
upon the Plasmodium of malaria. In order to be effective it 
should be administered in the above dose several times a day for 
about ten days. It can hardly be said to take the place of 
quinine although it seems to be as effective as quinine in pro- 
moting the destruction especially of the crescent form of the 
malarial parasite. 

Another remedy that sometimes acts beneficially in malaria 
is eucalyptus. This drug may be given either in the form of 
the fluid extract in one drachm doses several times a day or as 
the alcoholic tincture in doses of two to four teaspoonfuls, or as 
encalyptol, in doses of ten to fifteen minims (0.6 to 1 gm.) in 
capsule, two or three times a day. 

Of other remedies like antipyrin, carbolic acid, acetanilid, 
phenacetin and many more that have at different times been 
recommended for the treatment of malaria, very little need be 
said. One is rarely called upon to consider other drugs than 
quinine, methylene blue and eucalyptus, and the efficacy of 
all the other series of remedies is, moreover, exceedingly doubt- 
ful. 

Arsenic, however, has a very distinct place in the treatment 
of malaria. Arsenic possesses no lethal effect upon the Plasmo- 
dium, hence it is of very little value in the treatment of acute 
cases. It is highly useful, however, in protracted, chronic, sub- 
acute forms of the disease, especially with malarial cachexia. If 
marked nervous disturbances develop in the course of malaria, 



MALARIA 549 

arsenic is best administered in combination with, quinine either 

in the form of arsenious acid, sodium arseniate or as Fowler's DoS( ; and ad- 
ministration 
solution by mouth, as described in full on page 73, or, best of all, 

hypodermically, as the cacodylate of soda in half- grain to one 
grain doses, in watery solution, once or twice a day. There is 
no advantage in using quinine arseniate, in fact the administra- 
tion of the two remedies separately allows easier regulation of 
the dose of each drug (see above). 

One of the most disagreeable and obstinate symptoms of Splenic tumor 
chronic malarial intoxication is a persistent splenic tumor; and 
an important part of the after-treatment of malaria is the re- 
duction of the size of the enlarged spleen. As a rule a continued 
course of quinine, or of eucalyptus, or of arsenic will bring about 
the desired result. If the splenic tumor persists despite the ad- 
ministration of these remedies, then the injection of quinine In J ec tions 
directly into the spleen, or even splenectomy, must be considered. 
The insertion of a hypodermic needle into the spleen is, however, 
a precarious procedure (see page 93). 

From a series of clinical reports that have emanated particu- Acupuncture 
larly from Italian clinics, it seems that the insertion of the 
needle, itself, without regard to what substance may be injected, 
exercises the same effect that is occasionally observed when qui- 
nine or carbolic acid, or other remedies, are injected into 
the spleen substance. Hence the insertion of a sterile needle 
under aseptic precautions should answer the same purpose as 
the injection of any drug into the organ. This procedure, how- 
ever, should be carried out under the most careful aseptic pre- 
cautions and is best relegated to a surgeon. 

Faradization of the splenic region and the application of Faradization, 
heat or cold rarely exercises more than a transitory influence; Cold and Heat > 
exposure to X-ray is always worthy of a trial (see page 93). " r:iy 
With the reduction of the splenic tumor the cachexia frequently 
improves rapidly, hence every effort should be put forward to 
accomplish this result. 

In order to prevent re-infection with malaria and, generally To prevent 
speaking, as a prophylactic measure to be adopted on entering J^nces* recur " 
malarial regions, the administration of five to ten grains of 
quinine, two or three times a day, is to be recommended. 

The role of the mosquito and the means that must be adopted Role of the 
to prevent infection from this source are discussed in full in mos( l ulto 
the Section on Yellow Fever. 



550 



ACUTE ARTICULAR RHEUMATISM 



Early adminis 
tration of 
salicylates 



Salicylic acid 
and its deriva- 
tives almost 
a specific 



Large doses 
necessary 



Proper dosage 



Choice of prep- 
aration 



Dosage in 
children 



Salicylic acid 

Sodium sali- 
cylate 



ACUTE ARTICULAR RHEUMATISM— (Rheumatic Fever). 

At the onset of the disease with high fever, pain in one or 
several joint, often sore throat (tonsillitis) and the malaise, an- 
orexia, furred tongue and other phenomena attributable to the 
high fever, the patients should be put to bed and the adminis- 
tration of salicylic acid or salicylate preparations begun at once. 

Salicylic acid and its derivatives must be considered almost 
a specific in most cases of the disease. Its exact mode of action 
is not known. It exercises an influence upon the nerve ends, 
chiefly in the joints, relieving the pain, and it may also prob- 
ably possess some specific antibacterial and antitoxic action. 

In order to be effective large doses of the salicylic prepara- 
tions must be given. It is futile to give five or ten grains, three 
times a day; in order to accomplish the desired result doses of 
from sixty to one hundred and twenty grains (4 to 8 gm.) 
should be administered in the course of twenty-four hours for 
several days in succession. The remedy should, therefore, be 
given continuously during at least the first three days in doses 
of ten to fifteen grains (0.6 to 1 gm.) every three or four hours, 
day and night. 

The choice of the salicylic preparation is frequently difficult 
to make. Salicylic acid, itself, is said to act somewhat more 
quickly than any of the other preparations, but it is decidedly 
more irritating to the stomach than all its congeners. It should, 
above all things, never be given in solution, as it is soluble in 
water only in the proportion of one to five hundred, and as its 
solution in alcohol is so irritating as to preclude its internal ad- 
ministration in this form. If salicylic acid is to be given at all 
it should, therefore, be given in the doses mentioned above in 
capsules or powders, with milk. 

Sodium salicylate may be employed either in solution or in 
powder or capsule in the same dose as salicylic acid; as its 
taste is rather disagreeable it is best, however, not administered 
in powder form. The most agreeable way of dispensing it is in 
a solution of peppermint water with simple syrup. 

Children should receive smaller doses of salicylic acid, or 
of sodium salicylate, than those specified above. Children up to 
one year should not have more than fifteen grains (1 gm.) of 
either salicylic acid or sodium salicylate in the twenty-four 
hours; children from two to six should not receive more than 
thirty grains (2 gm.) in the twenty-four hours; and children up 
to twelve not more than forty-five or, at the most, sixty grains 
(3 to 4 gm.) each day. 



ACUTE ARTICULAR RHEUMATISM 551 

The best preparation of salicylic acid, the one that is the least Aspirin 
irritating to the stomach, bowel and kidneys, the one 
that hardly produces any of the toxic signs to be presently 
enumerated, even if given in very large doses, is aspirin. It 
may be given in thirty to forty-five grain doses (2 to 3 gm.) 
three or four times in the twenty-four hours; as its taste is not 
disagreeable it can be dispensed in powder form. 

In many cases of acute articular rheumatism in which large Poisoning from 
doses of salicylic acid, sodium salicylate or aspirin are given salic y lates 
symptoms of poisoning appear within a short time, manifesting 
themselves by visual disturbances, congestion about the head, 
buzzing in the ears, dizziness, nausea, vomiting. In especially idiosyncrasy- 
predisposed subjects having an idiosyncrasy against salicylic 
acid and its preparations, a single dose may produce violent 
symptoms of intoxication, headache, delirium, coma, retardation 
of the pulse, palpitation and drenching sweats. 

If these symptoms of intoxication appear one is often forced indications for 
to stop the administration of salicylates and to give other reme- stopP 111 ^ sali_ 
dies in their place. Occasionally only mild toxic symptoms will 
develop after the exhibition of one of the salicylic preparations. 
If the intoxication is not too severe it is always worth while to salol, sali- 
try to continue the salicylic therapy by using some other deriva- P n ® n > malakin, 
tive of salicylic acid, as salol (not in nephritis), saliphen, mal- cin, oil of 
akin, saligenin, salicin or oil of wintergreen, especially the lat- wmt ergreen 
ter in doses of twenty drops every two or three hours in milk or 
in capsule. 

The exhibition of salicylates by the percutaneous Percutaneous 
method, i. e., by means of ointments rubbed into the skin, is also 
a very useful mode of administration and one that can to ad- 
vantage be combined with the administration of salicylates by 
mouth. In cases in which symptoms of gastric irritation appear 
without any of the other signs of salicylic poisoning, the method 
of administering the drug by inunction alone is often effica- 
cious. Here ointments made of one part of salicylic acid to ten 
parts of lanolin, or of equal parts of oil of wintergreen and 
lanolin, are especially serviceable. 

Aside from the appearance of violent symptoms of intoxica- Contra-indica- 

tion in otherwise healthy subjects shortly after the exhibi- tic | ns Jo use of 

salicylates 
tion of salicylic acid preparations, there are distinct contra- 
indications to the use of these remedies, namely, cardiac disease, 
acute renal disease, congestion about the head and gastritis. 

If the patient is unable to take salicylic acid or its deriva- 
tives in large doses, then it is futile to continue their adminis- 
tration in small doses, and recourse is better had either to cer- 
tain other remedies to be now discussed or to local measures 
alone. 



552 



ACUTE ARTICULAR RHEUMATISM 



Remedies to 
replace sali- 
cylates 
Lactophenin 
Phenacetin 
Antipyrin 
Salipyrin 



Potassium 
iodide 
Guaiac 
vColchicum 

Alkalies 



Local treat- 
ment 



Hest of joints 



Meat and cold 



AlcoTiol dress- 
ing 



Alkaline 
washes 



Remedies that can in a measure replace the salicylates are, 
above all, certain of the coal-tar preparations, chief among them 
lactophenin, which may be given in ten to fifteen grain (0.6 to 
1 gm.) doses, every four hours; phenacetin in five to ten grain 
(0.3 to 0.6 gm.) doses; or antipyrin in five to fifteen grain (0.3 
to 1 gm.) doses, three or four times a day. A very useful anti- 
pyrin preparation is salpyrin, a combination of salicylic acid 
and antipyrin, which is used in the same doses as antipyrin. 
Guaiac, potassium iodid, colchicum and many other remedies 
that have at different times been recommended, nowadays no 
longer occupy a place in the therapeutic armamentarium to be 
employed against rheumatic fever. 

An energetic alkaline therapy instituted from the beginning 
of the disease and continued throughout its course, using alka- 
lies either alone or in combination with salicylates, is always 
useful. The patient should receive from five to fifteen grains 
(0.3 to 1 gm.) of bicarbonate of soda in a tumblerful of water 
or milk, four or five times a day. As a beverage lemonade or 
orangeade answers a similar purpose, for the citrates contained 
in lemon or orange juice are promptly converted into carbonates 
in the body. 

Local treatment in acute articular rheumatism is of much 
less importance than in chronic forms of articular disease. The 
chief object is to make the patient comfortable and this can 
best be done by arranging the pillows in such a way that cramp- 
ing and congestion of the affected joints are avoided, or by- 
applying rests or supports according to the requirements of the 
case. It is rarely necessary, nor can it be considered good prac- 
tice, to immobilize the affected joints, although, formerly, the 
adjustment of permanent splints, or even of casts, was in vogue. 

Some patients prefer hot applications, others are made more 
comfortable by the application of cold to the joints. Heat ap- 
plied by the hot air bath is usually most soothing, and if the 
house is wired for electricity a box lined with several incandes- 
cent globes can be placed over the joint several times a day 
with great relief to the sufferer. The thermophore (see index), 
hot water bags, or poultices are often grateful. 

A very effective dressing is the application of absolute alco- 
hol to the joints. A towel or several layers of gauze are soaked 
in absolute alcohol, applied to the affected joint and held in 
place by a loose bandage for eighteen to twenty-four hours. 
Simply wrapping the joint in cotton and bandaging loosely is 
of considerable benefit. Alkaline washes applied by means of 
cloths wrung out of a warm ten per cent, solution of soda and 



ACUTE ARTICULAR RHEUMATISM 553 

covered with flannel and renewed every few hours are useful. 
Salicylic ointment and oil of wintergreen ointment, as described Salicylic oint- 
above, can always be applied to the joint provided there is no ment 
idiosyncrasy against salicylic acid poisoning. 

Aside from the application of wet, hot or cold cloths to the Hydrotherapy 
joints other hydrotherapeutic means are of very subordinate im- 
portance in this disorder. General baths, warm or cold, are of 
no benefit, may even do harm, and are, above all, very disa- 
greeable to patients, because they are thereby forced to move 
about and deprived of their rest. Cleansing baths are, there- 
fore, best given by sponging in bed. 

The element of rest is exceedingly important, especially in Rest in bed 
view of the frequent involvement of the heart. Any sudden 
exertion, getting up quickly, going to the toilet should, there- 
fore, be forbidden. Upon the appearance of signs of endocardiac 
involvement an ice-bag should be intermittently applied to the ice bag to pre- 
precordial region and the other measures instituted that have cor ium 
been described in full in the Section of Acute Endocarditis, on 
page 49. 

The temperature of the room should be kept between 60 and 
65 degrees and the patient carefully protected from drafts and Room hygiene 
cold, especially moist air. If the house is moist, then the driest 
and most sunny room should be selected for the patient with 
rheumatic fever. The patient should wear a flannel night-shirt Clothing 
and sleep between blankets that are not too heavy and yet warm 
enough. In many instances the pressure of the blanket upon 
the affected joint is exceedingly trying to the patient. In such 
cases a suitable support should be arranged of wire or wood to 
protect the joints from such pressure. 

The diet should, in the beginning and during the stage of Diet 
fever, consist exclusively of milk. It can conveniently be given in 
the form of the milk-cream mixture described on page 27. Later 
when the appetite returns, the patient may receive other articles 
of food according to his tastes. While the importance of uric 
acid in the production of acute articular inflammations is very 
doubtful no harm can, nevertheless, be done by excluding from 
the bill of fare, during the acute stage of the disease, articles 
of food containing nucleins and articles containing extractives 
(purin bases), in other words all internal organs, young ger- 
minating plants, raw, rare, cured, smoked and corned meats, 
bouillons, meat extracts and gravies (see also Section on Uric 
Acid Di at lie sis). 

It is very important that sufferers from acute articular rheu- Treatment of 
matism should not get up too soon as there is always a tendency convalesence 



554 



to recurrences in this disorder. Sometimes the fever will become 
elevated several degrees during the stage of convalescence with- 
out any articular manifestations. In such cases the administra- 
tion of ten to fifteen grains (0.7 to 1 gm.) of salicylate of soda, 
or of aspirin, three or four times a day, for two or three days, 
is a useful measure to reduce the temperature and to prevent re- 
currence of articular troubles. In any event the patient should 
take small doses of salicylates, i. e., five to ten grains of sodium 
salicylate, or of aspirin, for several weeks after the fever has 
disappeared and all the articular manifestations have receded. 



Tetanue anti- 
toxin a specific 
prophylactic 



Effects in de- 
veloped te- 
timis 



Mode of action 



Indications 
for use of te- 
tanus antitoxin 



TETANUS. 

Tetanus antitoxin may be considered a specific prophylactic 
against tetanus. Given within a few hours after the premoni- 
tory signs of tetanus have made their appearance the remedy is 
occasionally efficacious. In fully developed tetanus, antitoxin 
is probably without value. It is very difficult to render conserva- 
tive judgment in regard to the curative virtue of tetanus anti- 
toxin in those instances of tetanus that run a protracted course 
and finally recover, because a considerable number of cases of 
tetanus progress towards spontaneous recovery without the ad- 
ministration of the antitoxin. The great majority of tetanus 
sufferers, however, that receive antitoxin in later stages of the 
disease succumb, nevertheless. Notwithstanding this ambiguous 
and largely negative evidence in regard to the efficacy of te- 
tanus antitoxin in fully developed tetanus the remedy should be 
given a trial, for no harm can ever accrue from its administra- 
tion, and it is possible that here and there an isolated case may 
be benefited by it. 

It appears that tetanus antitoxin possesses the power of 
neutralizing tetanus toxin while it is still circulating and before 
it has become permanently attached, so to say, to the ganglion 
cells of the central nervous system; when this attachment has 
occurred the remedy is apparently without effect. This pos- 
tulate would explain the value of the remedy as a prophylactic 
and its modifying influence upon the course of the disease if ad- 
ministered within twenty-four to thirty hours after the first 
signs of irritation of the cerebro-spinal axis have made their 
appearance, and its inefficacy in most cases if administered later 
in the disease. 

Tetanus antitoxin should, therefore, be used as a prophy- 
lactic measure in every case of trauma in which the wound is 
contaminated with dirt, especially manure, and particularly 



TETANUS 555 

if dirt or manure particles have been carried deep into the tis- 
sues where they are deposited in a location that is protected from 
the air; for the tetanus bacterium leads an anaerobic existence 
and flourishes best in the absence of oxygen. For this reason 
punctured wounds produced, for instance, by stepping upon a 
rusty, dirty nail, and wounds produced by explosions which 
send dirt particles deep into the tissues, as in Fourth of July 
injuries, are especially liable to be followed by tetanus. 

Tetanus antitoxin is best administered near the place of in- Place of in- 
fection. If the injury is about the head, or in other regions 1 ectlon 
of the body where it is difficult to inject large quantities of 
fluid under the skin, then at least a portion of the antitoxin 
should be injected near the seat of the injury and the rest in 
some other part of the body. 

The best method of administering tetanus antitoxin is by 
hypodermic injection. The administration by lumbar puncture Administration 
is also very useful, provided it is carried out under aseptic pre- kypodermi- 
cautions ; for the antitoxin is more rapidly absorbed from the bar puncture 
subarachnoid space than from the subcutaneous layers of the 
skin and, moreover, diffuses more rapidly through the cerebro- 
spinal fluid than through the blood. Intra-cerebral injections By the intra- 
possess no particular advantage over the injection into the spinal method 
canal and constitute, moreover, a procedure of some magnitude 
that requires special surgical skill, whereas lumbar puncture is 
a simple procedure that any internist should be able to perform. 

The intravenous method of exhibiting tetanus antitoxin is Intravenous 
not without danger and serious accidents have been reported m J ectlons 
from this practice. Moreover, it possesses no particular ad- 
vantages over the subcutaneous method or administration by 
lumbar puncture, for the effect produced is only slightly more 
rapid. 

At least one hundred antitoxin units, and not more than two Number of an- 
hundred units, should be injected during the first twenty-four t lto ^ in ^^ to 
hours. (Behring.) Injections of one hundred units should be 
repeated on several successive days. An antitoxic unit is that 
amount of tetanus antitoxin that can neutralize ten units of 
tetanus toxin in the test tube; and a tetanus toxin unit (Gift 
Einheit) is the smallest quantity of tetanus toxin that can kill 
a guinea-pig, weighing about 250 gm., in three or four days. 

Bacelli and his school warmly recommend carbolic acid, ad- Carbolic acid 
ministered hypodermically, as a prophylactic and a cure for C J^Z erm " 
tetanus. I have had no personal experience with this mode of 
treatment, but the reports emanating from Italian clinics are so 
positive and so favorable that the method may be mentioned. 



556 



Local treat- 
ment of the 
wound 



General man- 
agement 



Rest, protected 
from external 
irritants 



Hot baths 



Bacelli injects on the first day, either as a prophylactic or even 
after the tetanus spasms have set in, a two per cent, solution 
of carbolic acid in such amount that about three grains of 
carbolic acid are injected in the twenty-four hours. On suc- 
cessive days the amount of carbolic acid is increased to three or 
four times this quantity. It is claimed that tetanus cases show 
a great tolerance to carbolic acid and that the drug, adminis- 
tered in this way, exercises a beneficial effect upon the most dis- 
tressing symptoms of the disorder and materially shortens the 
course of the disease, producing a cure in many cases. 

The local treatment of the wound is of the greatest import- 
ance. The principles that should govern this treatment are to 
open the contused part by wide incisions so that free access of 
air may be favored even to the deeper regions. A careful search 
for dirt particles should be made, fistulous tracts should be ex- 
plored and the whole area laid wide open. Various antiseptic 
dressings, carbolic acid, salicylic acid, bichloride, etc., may be 
used according to common surgical principles. 

Aside from the specific treatment with antitoxin and the 
local surgical treatment, the general management of the case is 
of importance. Most patients with tetanus wear themselves out 
and die as much from the exhaustion produced by the spasms as 
from any specific lethal action of the tetanus poison; for this 
reason it is of paramount importance to preserve the patient's 
strength by reducing the number and the severity of the tetanic 
convulsions, while, at the same time, maintaining the nutrition 
of the patient to the maximum degree. 

An essential element in the treatment, therefore, is to protect 
the patient from all extraneous irritants — noises, light, contact 
with people and excitement of any kind — for in tetanus reflex 
irritability is enormously increased and the sufferers react with 
spasms or convulsions to stimuli that would normally not in- 
fluence them at all. 

A tetanus patient should, therefore, be put to bed in a dark- 
room and should be left as much as possible to himself. 

Hot bathing, two or three times a day, in water slightly above 
body temperature, is a very useful adjuvant to the treatment. 
The patients can, to advantage, be kept in warm water, half an 
hour at a time, two or three times a day. I have had the im- 
pression that this treatment reduces the number of spasms and 
is successful in shortening the convulsions, especially if the 
patients are placed into hot water immediately upon the onset 
of spasmodic symptoms. 

The question of feeding is often a difficult matter, espe- 



TETANUS 557 

cially if trismus is present. If there is much lockjaw, then the Diet and mode 
patient should be fed by rectum, as described in the Section on of feeding 
Gastric Ulcer, to be found on page 368, or, if necessary, through 
a nasal catheter. A patient with tetanus should receive large 
quantities of fluid, on the supposition that possibly the ingestion 
of much liquid will aid in diluting the circulating tetanus poison. 
Water should, therefore, be administered copiously by mouth 
and also by high enemata of warm physiological salt solution, fre- 
quently repeated. Immersion in hot water, coupled with free 
water drinking, unquestionably accelerates the lymph stream 
throughout the body and hence materially aids in keeping the 
toxin in circulation and possibly in preventing its attachment 
to the ganglion cells of the nervous system. 

Of remedies that can be given morphine occupies the first morphine 
place and it is good practice to keep the patient more or less 
under the influence of morphine throughout the course of the 
disease. The exact dose can hardly be stated. The patient 
should receive enough to control the spasms, so far as that is 
possible, and keep him quiet. 

If morphine fails to control the spasms, then chloral hydrate, chloral 
given in large doses of fifteen to twenty grains, four to six times hydrate 
a day,- by mouth or by rectum, should be substituted. Very 
violent spasms occurring despite the administration of morphine 
or chloral hydrate, can usually be controlled by a few whiffs 
of chloroform. If the chest muscles are in a state of rigid 
tetanic contraction, then, of course, it is very difficult for the chloroform 
patient to inhale at all, so that here chloroform inhalations 
cannot be given. In such cases hot compresses to the chest often 
aid in relieving the spasm and enable the administration of 
chloroform. 

Trional, tetronal, europhen, all given in doses of ten to thirty _ . , 
grains (0.6 to 2 gm.), three or four times a day are often effica- Tetronal 
cious. Tincture of thiosinamin, five to twenty drops (0.3 to Europhen 
1.2 cc.) ; or the extract of cannabis indica one-eighth to one- Thiosinamin 
fourth grain (0.08 to 0.06 gm.) or the fluid extract, two to five S^ 8 * 18 *"" 
drops (0.1 to 0.3 cc.) ; antipyrin in five to fifteen grain (0.4 to Antipyrin 
1 gm.) doses, repeated several times a day; bromide of sodium Bromides 
or potassium, finally, given alone or in combination with chloral 
hydrate, by rectum, in large doses of twenty to thirty grains 
(1.3 to 2 gm.) are the drugs that all merit trial and occa- 
sionally aid in controlling the most distressing symptoms. 



558 



DYSENTERY 



Definition 



Classification 



Catarrhal 
dysentery 



Tropical 
amebic dysen- 
tery 



Symptomatic 
dysentery 



No specific 
treatment 



Diet 



Calomel 



DYSENTERY. 

The term dysentery is employed to designate a number of 
disorders of different etiology that are all characterized by 
colic, tenesmus and the evacuation of small stools at frequent 
intervals, containing mucus and b^ood. One can distinguish 
between an epidemic and an endemic variety. In addition there 
are sporadic cases which are presumably isolated instances of 
the endemic variety. 

Epidemic dysentery is also known by the name of catarrhal 
dysentery and occurs chiefly when general hygienic conditions 
are very bad. Its course is milder and its mortality lower than 
in the endemic form. It is produced by different bacilli that 
are presumably introduced into the body through the drink- 
ing water. In the endemic variety, also known as tropical dys- 
entery, certain ameba must be incriminated with causing the dis- 
ease. Here the submucous layers of the intestine are usually 
affected, whereas in the catarrhal variety the surfaces of the 
mucosa show the first changes. 

In addition there are a number of forms of symptomatic 
dysentery that are produced by mechanical causes and that are 
due to a variety of intoxications. 

The treatment of all forms of dysentery is essentially the 
same and largely symptomatic, for we possess no specific treat- 
ment in the parasitic varieties. 

The diet should be non-irritating to the bowel and should 
leave a small residue. In the acute forms and until the severe 
colic, tenesmus, frequent diarrheas and the fever stop, the diet 
should be largely liquid and consist of milk preferably diluted 
with lime water, or strained gruels, or meat broths and soups. 
A very useful food is albumen water made by shaking the whites 
of twenty eggs in a pint or two of water, adding some sugar of 
milk and some flavoring extract. This quantity should be taken 
in divided doses in the course of twenty- four hours. In addition, 
the patients may have abundant water or lemonade or dilute 
wine. 

As soon as the acute symptoms subside a semi-solid diet may 
be permitted. A solid diet, however, should ^.ot be given until 
all blood and mucus have disappeared from the feces, and the 
diarrhea, the colic and tenesmus have been altogether relieved. 
The diet, in other words, does not differ materially from that 
advised in typhoid fever or in any other form of acute intestinal 
catarrh. 

Of medicaments that should be administered by mouth, calo- 



DYSENTERY 559 

mel, given in small (one-fourth grain) doses throughout the dis- 
ease is the sovereign remedy. It acts beneficially both on account 
of its laxative and its antiseptic properties. Vegetable laxatives 
should not be given in this disease as they are apt to be too irri- Laxatives 
tating. Small doses of castor oil or of olive oil can do no harm. 
If there is much constipation, especially in the beginning, a 
brisk saline laxative is indicated. 

Very popular, especially in the tropical variety of dysentery, Ipecac 
is ipecac. In the different countries it is given in different ways. 
The most sensible and least harmful method of administering it 
is the one recommended by English physicians in the British 
colonies; viz: The patient is first given a hypodermic of one- 
fourth grain of morphine, hot turpentine stupes are then ap- 
plied to the abdomen and an hour after the administration of 
the morphine, one grain of the root of ipecac in capsule is 
given, followed by copious draughts of water. This dose is re- 
peated two or three times in one or two hour intervals. In this 
way large quantities of ipecac can be introduced without pro- 
ducing distressing retching and vomiting. 

In the acute form astringents may be given, chief among them Astringents 
tannin. It is best given in the form of tannalbin, in doses of / 

thirty to fifty grains a day in divided doses of ten grains each. 
Naphthalin, preferably in combination with calomel, acts very 
beneficially both upon the colic and tenesmus and the charac- 
ter of the stools. Kartulis recommends the following prescrip- 
tion: 

Naphthalin, 1.0 gm. 

Calomel, 0.5 gm. 

M. : Make ten such powders. 

S. — One powder every two hours. 
In addition to these remedies narcotics, opium and prefer- 
ably morphine, hypodermically, may have to be given as pallia- 
tives to relieve particularly distressing symptoms. 

The rectal administration of medicines is especially useful in . _. 

this disease, because in this way the seat of the trouble can be tion 
best reached. For very violent tenesmus small laudanum-starch 
enemata should be given. 

Laudanum, 10 drops 

Starch, 1 tablespoonful 

Lukewarm water, 200 cc. 
Or 

Cocaine, 1 gm. 

; Water, 250 cc. 



560 



INFLUENZA 



Enteroclysis 



Chronic dysen- 
tery 



For severe hemorrhage and colic, sulphate of soda is useful 
3 



Sodium sulphate, 



10 g. 



Water, 250 cc. 

Or a dilute solution of iron perchloride, or ice water alone r 
injected in small quantities into the rectum are all effective. 

More valuable than the use of enemata is treatment by entero- 
clysis, for it promotes cleanliness of the lower intestine and, at 
the same time, enables the application of healing remedies directly 
to the affected lining membrane of the bowel. The ordinary 
antiseptics like carbolic acid, corrosive sublimate or the salicyl- 
ates are too irritating. The same applies to silver nitrate whose 
astringent properties might otherwise be employed to the advant- 
age of the patient. Other antiseptic remedies are insoluble in 
water and can consequently not be utilized (iodoform, naph- 
thalin, etc.). The chief remedies that can be employed advant- 
ageously are tannin and quinine, the former to be used in half 
per cent, solution, the latter in warm solutions of the strength of , 
1 to 1000 to 1 to 5000. From two to three litres of fluid should 
be used two or three times a day. The irrigating bag should not 
be elevated very high, as otherwise too great pressure may be ex- 
ercised upon the bowel wall and perforation occur. 

In chronic dysentery practically the same remedies are use- 
ful. Here again warm quinine solutions or solutions of tannin 
are very helpful. Internally, tannalbin, calomel and naphthalin 
are the chief remedies. 



Treatment 

exclusively 

symptomatic 



Antineuralgics 



INFLUENZA. 

The treatment of influenza, owing to the fact that we pos- 
sess no specific remedy, is exclusively symptomatic. Upon the 
onset of the first symptoms, energetic diaphoresis should be stim- 
ulated by hot baths, hot drinks, quinine, Dover's powder, as de- 
scribed in the Section on Acute Bronchitis. An influenza patient, 
however mild the onset of the symptoms, should be placed to 
bed and kept there until the temperature is normal. The diet 
should be bland and non-irritating, in other words, should con- 
sist of the ordinary fever diet (see page 509). 

Of remedies the ordinary antineuralgics are the most useful, 
for they make the patients more comfortable, reduce the sever- 
ity of all the symptoms and, above all, stop the distressing head- 
ache, backache and restlessness. It is always well to inaugur- 
ate the treatment with a full dose of calomel, followed by a 
saline laxative. The most useful remedy in my hands has been 



PERTUSSIS 561 

aspirin in combination with quinine, of each five grains, to be Aspirin 
given every five hours for three or four days. Salipyrin and 
antipyrin are less safe on account of their effect upon the heart. 
Alcohol is always useful. A little whisky and water given Alcohol 
throughout the course of the disease aids materially in counter- 
acting the heart weakness and symptoms of nervous depression 
that so commonly supervene in influenza. 

Hydrotherapeutic means are of subordinate importance in 
the treatment of this disorder, owing to the comparatively short 
duration of the disease. There is no harm in using the above Hydrotherapy 
antipyretic drugs and no advantage is to be gained from at- 
tempting a reduction of the fever by the more complicated hydro- 
therapeutic measures. Symptomatically, hot bathing, in fact, is 
always more useful than cold hydrotherapeutic means and a hot 
bath given once or twice a day, with an ice bag or cold cloths to 
the head, is often helpful. 

The treatment of the complications is synonymous with the 
treatment of the organs affected and will be found discussed in 
the chapters on Digestive, Respiratory and Cardiovascular Dis- 
orders. 



PERTUSSIS. 
(By Dr. Frank Spooner Churchill, Chicago.) 

Two principles may be laid down in the management of principles 
whooping-cough, viz., take every precaution possible to prevent 
infants and children from contracting the disease; when once 
contracted, treat the individual, not the infection. 

Much can be done, in private practice especially, to guard Prophylaxi 
infants and young children against contracting pertussis. The 
popular idea that this disease is a trifling affair, that ' ' they have 
all got to have it and the sooner they have it the better, ' ' is for- 
tunately disappearing. Intelligent mothers now try in every way 
to prevent their children from contracting the disease. They 
guard them rigidly, and properly so, from exposure in this direc- 
tion. Infants and young children should not be allowed to 
play either indoors or outdoors with others who have whooping- 
cough. Weak, debilitated children, especially those with a tend- 
ency to respiratory troubles, tubercular or non-tubercular, should 
not be allowed to attend kindergarten or any public gathering 
of children, both because the time thus spent indoors ou.eht to 
be spent outdoors, and because there is great risk of contracting 
all contagious diseases at such gatherings. Nor should they be 
allowed to play with children who have in any way been exposed 



562 



PERTUSSIS 



to whooping-cough but have not yet manifested any signs of the 
disease themselves. The latter may be in the incubative stage 
of the infection and therefore capable of spreading it. 

All children with a suspicious cough, except those who have 
already had pertussis, should be excluded from contact with 
other children. The early diagnosis of whooping-cough is often 
a difficult matter and until one is sure that a hard cough is not 
a manifestation of this infection, a child with such a cough 
should be withdrawn from association with other children. A 
Xymphocytosis high percentage of lymphocytes is strong confirmatory evidence 
of the disease and justifies isolation, temporary at least; for it 
has been shown* that in over ninety per cent, of cases of per- 
tussis there is a marked lymphocytosis, even in the catarrhal 
stage before the development of characteristic symptoms, and 
that this lymphocytosis rarely if every occurs in other respira- 
tory affections accompanied with a hard cough. 

"We cannot emphasize too strongly the importance of these 
rigid precautions, especially for infants and young, weakly chil- 
dren among whom the disease is most severe and so often fatal. 
They should be guarded against it, at least until they are older 
when it will be a much less serious affair for them. It is of 
course impossible to observe this great care in the congested dis- 
tricts of our large cities, but even here more care can be exer- 
cised than is generally done. The practice of directing patients 
with whooping-cough to "return" to the clinic cannot be too 
strongly condemned. It is wrong to the other patients, it has 
a bad moral effect upon the students, confirming them in their 
lay idea that the disease is a trifling affair. The physician who 
practises this custom is criminally negligent. 

It must be remembered that pertussis is a self-limited dis- 
ease, runs a certain course and that we have no means of cut- 
ting it short. Obviously then, the indications are to keep the 
individual in the best possible fighting trim that he may have 
the strength to outlast the whooping-cough organism and to sus- 
tain the attack with as little damage to himself as possible. This 
is best done by careful attention to his general hygiene and diet. 
Medication is a matter of secondary importance. 

The patient should have an abundance of fresh air ; he should 
be out-doors as much as possible in the daytime and at night 
should sleep in a well-aired, well- ventilated room. He may sleep 
out-of-doors during the spring, summer and autumn months in 
the north temperate zone. In dealing with infants and young, 



General hy- 
giene and diet 



*Churchill. Journal A. M. A., 1900, XLVL, 1500. 



PERTUSSIS 563 

debilitated children, however, care and judgment must be used 
in exposing them to the severe winter weather of a northern cli- 
mate. Large, well- ventilated, well-lighted rooms, one for the day 
and one for the night, are undoubtedly better for some of these 
patients than the indiscriminate application of the "fresh-air" 
treatment. Individual peculiarities must be heeded and the pa- 
tient treated accordingly. Those children who live in the con- 
gested districts of cities, and for whom fresh air, indoors or out- 
doors, is an impossibility, should be sent to a hospital and later 
to a convalescent home or camp in the country. 

A change of locality, as from sea-shore inland or vice-versa, climate 
is often of benefit, especially where the cough is unduly pro- 
longed. The Atlantic seaboard from Cape Cod south is especially 
desirable for such patients. The balmy air and comparatively 
warm sea bathing have a most beneficial effect upon them. Those 
who cannot have this change of environment will be much bene- 
fited by long hours spent in the parks, at the lake or river front 
where these localities are clean. 

Next in importance to fresh air for older children, and Nourishment 
equally important with it for infants, is the question of nourish- 
ment. Those infants fortunate enough to be at the breast should 
be kept there. Those not at the breast should have their diet 
carefully regulated and be put on cow's milk modified to the 
needs and capacity of the individual infant. It, is among this 
class of patients that whooping-cough is so serious and so often 
fatal, as has already been said. The disease wears out the baby 
either by itself or by the development of pneumonia or some 
other complication. Hence the maintenance of his nutrition is 
vital. 

The diet for older children should be largely liquid and Character of 

. the diet 

easily digested. Meals are necessarily irregular ; the child is so 

apt to lose a whole meal by a paroxysm coming on soon after 
eating that he must be fed again in a short time. He snouia re- 
main quiet for at least an hour after the hearty meals of the day. 
Paroxysms are apt to come on at evening soon after the child 
falls asleep, possibly due to the recumbent position; hence it is 
advisable either to give the evening meal earlier or to put him 
to bed later that digestion may be further advanced before the 
paroxysm comes on. 

The bowels should of course be kept freely open. Where Laxatives 
this cannot be done by a diet rich in fruits and vegetables, laxa- 
tives must be used. The fluid extract of cascara sagrada (aro- 
matic) is excellent for this purpose; it may be given in doses of 
ten to thirty drops one to three times a day, according to results. 
Phosphate of soda in drachm doses may be given every morning. 



564 



PERTUSSIS 



Stimulants and 
tonics 



The paroxysm 



Medication 



Belladonna 



A thorough clearing out of the intestinal canal once or twice a 
week is often of benefit; for this purpose one grain of calomel, 
in one dose, or a drachm of castor oil may be given in the morn- 
ing. 

Stimulants must be used in some cases even when no com- 
plications are present. Brandy is the best form of alcohol to 
give as it is less likely to upset the stomach than whisky. Strych- 
nine in doses of one-one-hundredth of a grain may be given to 
older children. Iron and cod-liver oil are often indicated in the 
later stages with considerable debility and anemia. 

THE TREATMENT OF THE PAROXYSM. 

There is little to be done when the paroxysm of whooping- 
cough is actually on in older children. Young infants, how- 
ever, should never be left alone during the paroxysmal stage on 
account of the danger of strangulation. They must be taken up 
during an attack, held face downward and often it is necessary 
to clear out the mucus from the throat with the finger. A severe 
paroxysm which threatens suffocation may be relieved by in- 
haling oxygen or ether. Intubation has even been done for 
such. Chloroform should not be used on account of the possi- 
bly weak condition of the heart so frequently present in whoop- 
ing-cough. 

Medication is of far less importance than the details of gen- 
eral treatment insisted upon above. A few drugs, however, do 
seem to diminish the number or severity of the paroxysms and 
these should be tried. They may be given (a) internally, (b) 
by inhalation, (c) by insufflation. 

(a) Internally. All the drugs in the pharmacopoeia have ap- 
parently been recommemli rl for the treatment of pertussis, but 
of them all only a few have wtood the test of time and experience. 
These are belladonna, quinine, phenacetine, antipyrine and bro- 
moform. It is better to delay the use of drugs until the paroxys- 
mal stage is well under way; one preparation at a time should 
be given a thorough trial; if benefit seem to come from its use 
continue it, if not, stop and try another. Some cases are so mild 
throughout that no medicine at all is necessary. 

The effects of this drug must be carefully watched. It 
should be given at first in small doses, one-fourth minim of 
the fluid extract to an infant eighteen or twenty months old, 
every four hours, gradually increasing to one-fourth minim every 
two hours. Atropine also may be given in the same way, begin- 
ning with about one-eight-hundredth grain. Undoubted benefit 
seems to follow the proper use of these preparations in most cases, 
but they must be pushed to the limit, until the flushed face and 



PERTUSSIS 



565 



dilated pupils are noticed. The best results are seen in hospital 
cases which are under constant supervision. 

This may be given to older children. It should never be Quinine 
given to infants. It must be administered in large doses, ten to 
fifteen grains daily to a child five or six years old. If it dis- 
turbs digestion it must be stopped. 

These preparations allay the' severity and frequency of at- Phenacetine 
tacks in many instances. They are particularly valuable where an an ipyTin 
much sleep is being lost and the child is in an irritable and fret- 
ful condition. They should be given always with a stimulant, 
brandy, whisky, coffee, caffein, etc. They may be given in fairly 
large doses; one grain every two to four hours to a six months 
old infant. To an infant eighteen to twenty months old, two 
grains every two hours may be given. For older children larger 
doses in proportion to the age are prescribed. It is recommend- 
ed by some to combine the bromide of sodium with these coal- 
tar products. I have had no personal experience with this 
method- 

This is one of the more recent preparations. It seems to be Bromoform 
of value in some eases. It is given in doses of one to three drops 
every two or three hours to an infant two years old, and three to 
five drops every two hours to a five-year-old child. All prepara- 
tions must be shaken before using and it may be given on a lump 
of sugar. 

I have found phenacetine the most satisfactory of the above 
drugs. It has been prescribed always with a stimulant, brandy, 
to weak, debilitated or exhausted children, caffein (one quarter 
grain) and sugar of milk (ten grains) to others. 

(b) Inhalation. The administration of drugs by this method 
and by insufflation is based on the theory of the local nature of 
pertussis and aims to allay the irritability of the respiratory 
mucous membrane. Inhalation is more effective than insuffla- 
tion. The preparations most commonly used are creosote, creso- 
lene and carbolic acid. Cresolene is especially valuable. It is 
used generally at night and may be evaporated on a special lamp 
or an ordinary croup kettle may be used. The windows of the 
bedroom may or may not be kept open, according to the effects 
produced. The possibility of poisoning from these drugs must 
be remembered and the urine watched. 

(c) Insufflation. But little has been accomplished by this 
method and it is seldom used at present. Quinine is most com- 
monly used, mixed with some bland powder (1:10), such as 
bicarbonate of soda, acacia, talcum or coffee. Antipyrine has also 
been used in this way. 



Cresolene 



566 PAROTITIS 

The local application of cocaine to the larynx is dangerous 
and should not be done. 

Stage of decline The management of the stage of decline in pertussis requires 
but brief mention. The diet can now. be increased, more solid 
food being given. Life in the open air should be continued. 
The change of environment in prolonged cases has already been 
mentioned. But isolation should be continued for at least four 
weeks after the cessation of the paroxysms. The possibility of 
the development of tuberculosis at this time must be borne in 
mind. 

Complications The most serious complication of pertussis is broncho-pneu- 

monia. Its management is the same as that of pneumonia from 
other causes, being mainly supportive and stimulating. Rest 
in bed, an abundance of fresh air, baths, warm or cold, accord- 
ing to the child's temperature, his vigor and general condition; 
as nutritious a diet as possible and stimulants are the main prin- 
ciples to be laid down. Stimulants must be used freely ; brandy 
and strychnine are the favorite ones ; carbonate of ammonia and 
nitro-gycerine are also used. Inhalations of steam, plain or 
medicated with creosote, are of great help and should be freely 
used. 

While pneumonia is the most frequent complication during 
the winter months, gastro-intestinal trouble is of frequent occur- 
rence in infants during the summer weather, and is a serious 
matter. Proper feeding from the outset will do much to prevent 
its development. Once established its management is that 
usually adopted under such conditions: emptying and disinfect- 
ing the digestive tract, modification of the diet, etc. If vomiting 
is very persistent we have to resort to rectal feeding to keep up 
the patient's nutrition. 

Convulsions, severe hemorrhages, albuminuria, etc., are to be 
treated according to general principles. 



Hygiene 



Hydrotherapy 



PAROTITIS. 

(By Dr. Frank Spooner Churchill, Chicago.) 

Mumps is generally a mild disease, and but little active treat- 
ment is required. The patient should stay in the house, except 
during warm weather, until the acute symptoms have subsided. 
In the more severe cases, however, accompanied with high tem- 
perature and general constitutional disturbance, more energetic 
measures must be taken. He should then, of course, be kept in 
bed, the bowels kept freely open, baths as in pneumonia or 
typhoid may even be necessary in especially severe cases, and 



SCARLET FEVER 



o67 



antipyretics may also be used. Phenacetine, prescribed as in 
pertussis, relieves the pain and general discomfort. Sweet 
spirits of nitre is also of value. Hot applications to the swollen 
and tender glands are often acceptable. A mouth-wash should Drugs 
be freely used, and for this purpose listerine is an excellent prep- 
aration. The diet must be liquid on account of the pain in Diet 
swallowing. 

Complications are rare in early childhood. Later, especially Complications 
in early youth, the most serious complication is an orchitis. If 
present the patient must be kept rigidly in bed, the gland being 
supported and hot or cold applications made. He should be 
kept in bed until the acute symptoms have subsided and on get- 
ting up a suspensory bandage should be worn for several weeks. 

Otitis and nephritis occur but rarely. They should be treated 
on general principles. As in all infections, the urine should be 
examined both during and after the acute stage of the disease. 

Suppuration of the parotid rarely occurs, but if it develop 
it should be treated on surgical principles. 

Children with mumps should be excluded from school and 
quarantined for three weeks from the beginning of symptoms. 



SCARLET FEVER. 
(By Dr. Win. L. Baum, Chicago.) 

In view of the high mortality during early life and the de- 
creasing susceptibility and danger with advancing years prophy- Prophylaxis 
laxis becomes a most important factor. Unfortunately, during 
the incubation period, the contagion may be spread. This is es- 
pecially true when a case appears in a family or in a school. The 
case should be isolated at once and the rooms frequented by the 
patient thoroughly disinfected. 

The room occupied by a patient can be disinfected by means 
of formaldehyde, although this method is not so satisfactory and 
thorough as is the washing of the walls and furniture with a 
1-2000 bichloride of mercury solution, and the boiling of the 
bed linen, clothing, etc. In hospitals, the formaldehyde disin- 
fection is not so satisfactory. At the Cook County Contagious 
Hospital, where this method has been most thoroughly tried, 
cases of scarlet fever have been known to develop in a room 
subsequently occupied by patients suffering from other diseases. 
This was not the case where the bichloride washings were em- 
ployed. It is needless to say that the attendants should be iso- 
lated and exercise the greatest precautions in their relations to 
the family and others to prevent the spread of the disease:. 



568 



SCARLET FEVER 



Isolation 



Mouth disin- 
fection 



Sera 



Patients should not be allowed to leave the room until free 
from contagion and until desquamation be complete. Isolation 
should average at least six weeks. The minimum period of ex- 
clusion from school should be seven weeks. During the week 
preceding the discharge, the patient should have at least two 
baths in a solution of sublimate of the strength of 1-5000. The 
clothing should be disinfected with steam or by boiling. This 
is particularly true of clothing worn by the patient at the be- 
ginning of the attack. In one case isolation was carried out for 
eight weeks and it was thought every precaution had been taken. 
Four weeks after the patient's discharge his little brother was 
sent to the hospital. Five days previously the elder brother had, 
for the first time since discharge, worn the suit of clothes which 
he wore when first attacked, which clothes were the only articles 
that had escaped disinfection. 

Despite the claims made by certain authors and the antique 
use of belladonna, iodide of mercury and oil of eucalyptus as 
a prophylactic, there is no evidence that any medicinal agent will 
prevent infection. 

The patient should be placed in a room from which super- 
fluous furniture, such as carpets, pictures, etc., has been re- 
moved. The room should be kept at about 60° F. and well ven- 
tilated. There is no danger from air currents in the room. Bed 
coverings should be light. 

Care of the mouth, throat and nose is of the greatest impor- 
tance, since Hektoen has shown that streptococci enter through 
the tonsils. For this purpose sodium salicylate in 0.5 to 1.5 so- 
lution may be given in teaspoonful doses every two hours for 
the first four or five days, as suggested by Forchheimer. For a 
mouth wash a solution of boric acid, or one of potassium per- 
manganate 1-500 can be used. 

Much interest has lately been aroused by the employment of 
antistreptococcic serum. Its value must depend upon the as- 
sumption that the streptococcus is either the etiological factor, 
or that its presence is the cause of the toxic disturbances for 
whose control an antibody is necessary. Various serums have 
been employed. Marmorek's serum, which l have employed in 
the treatment of seventy-one cases, did not reduce the mortality 
or lessen the complications to any appreciable extent. Baginsky, 
whose early experience was of a similar character, later used the 
serum prepared by Aronson, reporting a series of sixty-two cases 
with a mortality oP 11.3 per cent., while sixty-three cases treated 
without the serum showed a mortality of 17.3 per cent. Escher- 
ich, of Vienna, uses a serum which differs from that of Aronson 
and Marmorek in that the streptotocci in immunizing the horse 



SCARLET FEVER 569 

were taken directly from man and without raising their viru- 
lence by passage through the lower animals. The animals were 
immunized by cocci from many instead of a single source. The 
dose of this serum varies from 100 to 200 cc. In Escherich's re- 
port of 112 cases treated with this serum, lie claims that in from 
four to twelve hours the temperature dropped; the pulse and 
respiration slowed down; the stupor and delirium disappeared; 
the general condition improved and the eruption faded. The 
serum causes transient exanthemas in about 75 per cent, of the 
cases. Since the use of the serum ulceration of the throat and 
suppuration of the glands have been less frequent. One striking 
feature of Escherich's report is the following: Of 27 cases in- 
jected within the first forty-eight hours of the disease, none died ; 
2 of 27 injected on the third day died, and 6 of 20 injected on the 
fifth day; a mortality ranging from nothing during the first 
and second day, through 7.4 per cent, the third; 17.4 per cent, 
on the fourth to 30 per cent, on the fifth day, a result striking 
in similarity to that following the use of antitoxin.* Owing to 
the difference in virulence of the various epidemics, and even of 
periods of the same epidemic, it is difficult to draw satisfactory 
conclusions as to the value of these methods of treatment. 

In my own service at the Cook County Hospital, comprising 
the period from February, 1895, to April, 1906, there were treat- 
ed 1672 cases with 125 deaths, or a mortality of 7.49 per cent., 
showing that the disease did not occur in a very virulent form 
during these years. A change in the epidemic was noted in De- 
cember, 1905 ; in the following four months there were 265 cases 
with a mortality of 13.6 per cent. 

Diet should, for the most part, be light, consisting chiefly of Diet 
milk-. The large quantity of water contained in it is of great 
value in these cases, especially toward the end of the third week, 
if there be no nephritis or other contra-indications. Diet can be 
gradually increased in quantity and variety. In the fifteen years 
elapsing since Jaccoud employed milk as a diet, he has not had 
a case of nephritis after scarlet fever. My own experience has 
not been quite as favorable. 

The early treatment should be directed towards securing free Eliminatlom 
elimination by way of the bowels and kidneys. This, when suc- 
cessfully accomplished, will in a large measure prevent the grave 
cardiac and renal disturbances. 

In many cases within a few hours from the first eruption, or 
even before its appearance, delirium or unconsciousness develop, 

♦Zanghofer, v. Bokay and Quest report a similar experience following 
the use of the Moser, also a polyvalent serum. 



570 SCARLET FEVER 

accompanied by suppressed or scanty urine. The urine is loaded 
Fulminant type with albumin, some casts and occasionally blood. These ful- 
minant cases should be treated by venesection and transfusion 
with normal salt solution. Water should be given from the onset 
in large quantities and diuretics employed. The best and safest 
is an infusion of birch leaves, 30 to 1000 cc. given in two table- 
spoonful doses every hour. This causes neither heart depression 
nor nausea, and usually results in a rapid increase in the kidney 
elimination. 
Baths The fever should be combated by means of the cold bath or 

sponging with cold water (antipyretics should never be em- 
ployed). The reasons for the use of baths may be best stated in 
the words of von Jiirgensen : ' ' The difference between the tem- 
perature of the body surface and the water that comes in con- 
tact with it are the determining factors. At the very moment 
that cold water comes in contact with the skin, deep respirations 
ensue, which not only cause a complete distention of the lungs, 
but must have a considerable influence upon the circulation. 

"The heart, which during the superficial breathing is work- 
ing under difficulties, is now relieved of the burden to a consid- 
erable degree, and receives more and a better quality of blood. 
Owing to this, its vitality and functional power increase. If the 
temperature of the body is increased, the number of the heart- 
beats decreases with the cooling caused by the radiation of heat 
to the water surrounding the body. The intervals between the 
single beats become longer, the diastolic storing away of the blood 
in the heart becomes greater, and the heart in this way becomes 
qualified for better work. At this point begins a more rapid and 
copious circulation throughout the entire system, and with it the 
possibility of throwing off the toxin.' ' 

The cold baths should last but a few minutes and the water 
should be at a temperature of about 65° F. Where the cerebral 
symptoms are marked the ice pack can be applied to the head and 
cold douches can be given to the back of the neck, and at inter- 
vals along the spinal cord. If the skin is cold and the tempera- 
ture high it denotes marked cardiac weakness and warm baths 
should be given. The contra-indications to the use of cold baths 
are cardiac weakness, organic disease of the heart, dyspnea due 
to stenosis of the upper air passages, hemorrhages from the nose, 
mouth, or a hemorrhagic diathesis; also when joint inflamma- 
tions are present. 
Urotropin Widowitz reports 102 cases in which urotropin was employed 

without a single case of nephritis ; others have used it, some with 
similar results and some claiming that it has no effect. The dose 



MEASLES 571 

varies with the age of the patient and is given three or four days 
in the beginning of the attack, and for three days at the begin- 
ning of the third week. 

When nephritis develops the bowels should be kept free by Nephritis 
the administration of repeated doses of magnesium sulphate, and 
the infusion of birch leaves given in large quantities, or the mix- 
ture of iron and ammonium acetate. The latter seems to do 
well in those cases where the nephritis is associated with anemia. 
When uremic symptoms develop very hot baths at a temperature 
of 110° F. should be employed. 

In cardiac weakness camphorated oil given hypodermically is 
probably the best stimulant. Infusion of digitalis with strychnin 
can also be employed. 

The early infection of the nose in the case of very young The nose and 
children should be treated by dropping a few drops of a solu- throat 
tion of sodium bicarbonate, 1 to 200, into the nostrils ; older indi- 
viduals employing it in the form of a douche. After each douche 
a little sterilized vaseline should be applied to the nostril. The 
severe angina if pseudo-membranous is usually due to the pres- 
ence of the Klebs-Loeffler bacillus and 5000 units of antitoxin 
should be administered at once. Painful angina is much relieved 
by allowing the patient to swallow small pieces of ice and apply- 
ing the ice pack about the throat. Enlarged and suppurating 
cervical glands should be incised when there is fluctuation, or 
earlier when the tension becomes too great. The Crede ointment otitis 
has proven useless in the treatment of the enlarged glands. The 
ears should be examined frequently as an otitis media due to ex- 
tension of the inflammation from the. throat through the Eustach- 
ian tube is a quite common complication. Should an otitis de- 
velop, paracentesis should be done at once and the ear irrigated 
every two hours with a hot boric acid solution until the discharge 
ceases. Mastoid infections are extremely rare when this method 
of treatment is followed. 



MEASLES. 
(By Dr. W. L. Baum, Chicago.) 
The almost universal susceptibility to measles and the fact p rev ention 
that sooner or later almost every individual will be attacked give 
rise to the interesting question whether it be better to guard 
the public against this infection or allow general exposure in 
the hope that for a generation at least the disease will disap- 
pear? No one who has witnessed the ravages of a virulent epi- 
demic with high mortality and severe complications, and their 



572 



The sick room 



The nose and 
throat 



Fever 



Broncho-pneu- 
monia 



far-reaching influence upon the future of the patients, can for 
a moment question the advisability of protecting the public 
as much as possible, both by compulsory isolation of the indi- 
vidual attacked and such regulations as tend to limit the spread 
of the disease. Unfortunately the period of incubation, espe- 
cially during the catarrhal stage, is capable of spreading the 
contagion. During prevalence of measles in a certain district 
public school teachers should be instructed to send home all chil- 
dren suffering from conjunctivitis or coryza, with instructions 
that they be examined by a physician. The finding of Koplik 
spots and the subsequent isolation of the patient may limit the 
spread of the disease. Disinfection of rooms and clothing, as 
employed in diphtheria and scarlet fever epidemics, will protect 
the community. 

The patient with an attack of measles should be placed in 
a well aired room kept at a temperature of 65° F. The air of 
the room should be kept moist because of the universal involve- 
ment of the mucous membranes. Dry air increases irritability 
of the bronchial tubes and predisposes to the most dreaded of 
all measles complications — broncho-pneumonia. The room should 
be partially darkened to protect the eyes; once a day the light 
should be freely admitted to make a careful examination of the 
conjunctiva and cornea. As a rule the eyes need no further 
care, but where there is much irritation an ointment of the yel- 
low oxide of mercury, 1-100, can be applied to the lids. 

The nose should be treated by dropping a small quantity 
of a solution of sodium bicarbonate, 1-200, into each nostril and 
the subsequent application of vaseline or oxide of zinc ointment. 
The throat and mouth should be washed out with a mild anti- 
septic solution — boric acid solution, 1-100, or postassium per- 
manganate, 1-500. Laryngeal spasm should be controlled by 
the administration of a small quantity of Dover's powder suit- 
able to the age of the patient. In severe cases warm baths are 
indicated. When the stenosis is due to swelling of the mucous 
membrane or to the formation of a plug of mucus in the trachea 
and larynx, an emetic should be given at once; apomorphin 
given subcutaneously acts most promptly. If these do not give 
relief, intubation or tracheotomy should be employed. 

For the fever antipyretic drugs should not be employed. 
Baths at a temperature of 85° F., or sponging, will reduce tem- 
perature. If there be much nervous irritability small doses of 
potassium bromide can be given in conjunction with aconite. 

Measles patients who develop broncho-pneumonia, that most 
dreaded of all complications, should be at once isolated from 
other cases of the disease. A cold pack may be applied, but 



SMALLPOX 573 

with small children care should, be taken that they do not be- 
come chilled. This tendency can be overcome by application of 
!n*at and friction to the extremities. The heart may be stimu- 
lated by the hypodermic use of camphorated oil. 

Where diarrhea is a feature of the eruptive stage treatment Diarrhea 
therefor is as a rule not necessary. Should it persist, small, fre- 
quently repeated doses of bismuth subgallate, with enemas of 
norma] salt solution every four hours, will usually relieve the 
condition. 

Extension of inflammation from the throat may lead to a 
suppurative otitis media. This if not relieved, leads to infection 
of the mastoid, necessitating operative interference. 

Weiss claims that by placing pledgets moistened with weak 
silver solution in the nostrils and carrying them backward by 
pressure, he has reduced the percentage of otitis in measles from 
27 to 7 per cent. Should suppurative otitis develop, the drum 
should be incised and irrigations of hot boric acid, 1-100, or 
protargol, 1-300, every three hours should be employed and 
kept up until the discharge disappears. 

During the eruptive period the diet should consist of milk, Diet 
eggs, and foods easily assimilated; later this may be increased 
to the full, regular diet during the period of convalescence. 

The patient with uncomplicated measles should be isolated 
for at least twenty-eight days; cases with persistent discharge 
from the nose or ears, for a longer time. 



SMALLPOX. 
(By Dr. Heman Spalding, Chicago.) 
The treatment of variola should begin with a consideration 
of the proper application of known preventive measures. Meas- classification 
ures commonly employed and known to be efficacious in prevent- of P reventlv e 
ing smallpox are: 

1. Notification of cases and suspected cases of smallpox to 
Boards of Health or Health Officers. 

2. Quarantine and Isolation. 

3. Disinfection of infected persons and premises. 

4. Vaccination. 

Notification. 
That prompt preventive measures may be taken by the 
rightfully constituted health authorities or health officers in Beports to 
states, cities and towns, there should be state laws and city ordi- health officers 
nances enacted, requiring, under penalty, a prompt report to 
the health officer of all infectious diseases. Cities have health 



574 



SMALLPOX 



Early diagnosis 



Guards 



Personal care 
of physician 



Home disin- 
fection 



ordinances and health officers to whom reports can be made. 
Some towns and villages are not thus provided, and when they 
are not, reports should be made to the county health officer or 
the state board of health. Physicians should promptly report 
any suspected case of variola. Owing to the lack of opportunity 
;.o see variola, the ablest of practitioners are liable to find it 
lifficult to make an early diagnosis of this disease. Any erup- 
i i ve disease not certainly understood should be promptly re- 
ported to the health officer as suspicious, throwing the respon- 
sibility of making a diagnosis upon that officer, who is, or should 
be, especially qualified for this work. It is the health officer's 
duty to see that the physician who reports a suspected Case of 
smallpox suffers no loss of confidence from the patient or his 
friends. The protection of the physician's interests is easily 
accomplished if the health officer is tactful and ethical, as he 
always should be. 

Quarantine and Isolation. 
If the victim of smallpox is to be treated at his home, as is 
the practice in small towns and the country, a strict quarantine 
of the house must be maintained. As no quarantine is effective 
if not complete, guards for the house must be stationed day and 
night, and no one except the attending physician or health 
officer allowed to enter or leave the infected house. 

The doctor should have a robe or a long rubber coat hanging 
outside the house to put on while visiting the patient, to be 
again removed upon coming out. He should then wash face, 
hands and hair in a 1 to 500 bichloride of mercury solution and 
sponge off his clothes and soles of his shoes with the same solu- 
tion. While in the house visiting the patient, the doctor should 
avoid, when possible, touching anything except the floor with 
the soles of his shoes. If there is no contact with anything in- 
fected, there is little liability of carrying infection to others. 

To quarantine smallpox in the house is expensive and less 
efficient in checking the spread of the disease than is the prac- 
tice of taking all patients to an isolation hospital. In the lat- 
ter practice the patient is at once taken to the hospital in a 
carriage or ambulance. Those suffering with the mild form of 
the disease, and even some of the severer cases, when found on 
the first day of the eruption, prefer to go in a carriage. At 
this period of the disease they usually are able to sit up and 
walk. All persons exposed to the case are vaccinated and the 
persons and premises disinfected with formaline and a free use 
of bichloride of mercury solution, 1 part to 500 of water. If 
the victim of the disease has remained home through the pustular 



SMALLPOX 575 

stage of the disease, it is safer to burn the mattress and 
all bed covers used which cannot be immersed in the bichlo- 
ride solution and boiled. Nothing should be taken from the in- 
fected house, even to be burned, that has not first been wet with 
the bichloride solution. 

After the patient is placed in the hospital and the inmates 
of the infected house and the premises are disinfected, and if all 
the inmates have submitted to vaccination and will obey orders, 
no quarantine is necessary. All those exposed are required to Care of persons 
be at home where they can be seen at least every other day for expose 
eighteen days. In no other respect need their movements be re- 
stricted. They are advised to stay away from public gatherings 
and to remain at home as much as possible, to escape criticism 
from neighbors. 

The moment any of the exposed shows symptoms of the 
disease, he is placed in a room and the other inmates required 
to stay in the house. When the eruption appears, which occurs 
on the evening of the third or morning of the fourth day of the 
disease, the diagnosis is complete, and the patient now in turn 
is taken to the isolation hospital and the house is again disin- 
fected, but now there are no unvaccinated persons who are ex- 
posed. The house is free from smallpox and no further watching 
is needed. 

Disinfection. 

In addition to burning mattress and bed covers not easily Method of dis- 
disinfected by the soaking in a disinfecting solution and boiling, infection 
and the free use of the disinfecting solution, a formaldehyde dis- 
infection should be made as follows : 

The house to be disinfected is sealed and prepared as usual 
for sulphur disinfection by pasting strips of paper over cracks 
of doors and windows. All its surfaces are exposed as much as 
possible; closet doors are opened and their contents, together Preparation of 
with the contents of drawers, are removed, scattered about and rooms and con- 
the drawers left open; mattresses are set on end; pillows, bed- 
ding, clothing, etc., are suspended from lines stretched across 
the rooms, or spread out on chairs or other objects so as to ex- 
pose, all sides; books are opened and the leaves spread — in 
short, the rooms and their contents are so disposed as to secure 
free access of the gas to all parts as fully as possible. 

For every 1,000 cubic feet of space in the house, suspend Formalin 
by one edge an ordinary bed sheet (2x2^2 yards) from a line 
stretched across the middle of the rooms. Properly sprinkled, 
this will carry without dripping eight ounces of formalin — 
the 40 per cent, solution of formaldehyde gas — which is suf- 



ical inspectors 



576 SMALLPOX 

ficient to disinfect 1,000 cubic feet of space. As many sheets 
as necessary are used, hung at equal distances apart. The ordi- 
nary rather coarse cotton sheet should be used in order to secure 
rapid evaporation. The house should remain sealed not less than 
eight hours. 

When an isolation hospital is to be built, or hastily provided 
as is usually the case, see to it that the structure is good enough 
to be occupied by the best citizens. It should be a place to 
which the mayor and members of the council would be willing to 
take members of their families if any should be stricken with 
smallpox. 

A proper method of handling smallpox is fairly revealed in 
the writer 's written instructions to medical inspectors with whom 
he has been associated in suppressing smallpox in Chicago, which 
reads as follows : 
Duties of med- ' ' Medical Inspectors must keep in close touch with the De- 

partment of Health, so they may be reached without delay when 
wanted. 

''When notified of a suspected case of smallpox, the inspec- 
tor must go to the case forthwith. An hour's delay may result 
in many needless exposures. 

"The following suggestions as to conduct in the presence of 
smallpox should be observed so far as the circumstances of the 
case will permit with safety. The inspector must supply any 
deficiency in these instructions which the case may demand for 
the safety of the public. 

"On entering the house where there is a suspected case of 
contagious or infectious disease, do not remove your hat or 
overcoat; keep the overcoat buttoned. 

"Do not shake hands with any one in the house. Do not 
sit down or touch anything in the house, and especially avoid 
touching the patient or bed clothing. To expose the patient for 
examination, call upon the patient or some one present to re- 
move the clothing for you. When leaving the house, have some 
one open the door, so as to avoid touching any infected door 
knob. 

"Except to vaccinate the inmates of the house, it is not 
necessary to touch anything about the premises, except the 
floor with the soles of your shoes. If these precautions are 
observed there is no danger of carrying the disease to others. 

"When it is determined the case is one of smallpox, fill out 
the history blank provided for the purpose, telephone the in- 
formation to the department, and promptly mail the filled blank 
to the Chief Medical Inspector. Telephone instructions as to 



SMALLPOX 577 

the disposal of the case, whether an ambulance or a carriage is 
needed, the amount of disinfecting to be done and the number 
of vaccinators needed. 

"In filling out the blank, secure a list of all who have in 
any way been exposed to the contagion since the first day of 
the sickness, learn if letters or laundry have been sent out of 
the house, and where and to whom sent. Give the vaccinal 
status of those exposed as far as you can. 

"It is the duty of the inspector to vaccinate, or see that some 
other medical inspector vaccinates, all who are known to be 
exposed to the infection; do not leave or allow this duty to be 
done by the family physician. It is the duty also of the inspec- 
tor to secure the consent of the patient or family for the removal 
of the patient to the isolation hospital. Do not leave this duty 
to the ambulance driver. 

"Until the ambulance comes the case must be made safe. 
If it is necessary to police the house to secure safety, do so. 
After securing the prompt vaccination of all exposed, it is the 
inspector's duty to see the exposed every other day for fifteen 
or twenty days. Repeat the vaccination every day for three 
days without waiting to see the result of the first trial. 

' ' If there is doubt about the diagnosis, vaccinate the inmates 
of the house, make the case safe to others and see the patient 
later. 

"A medical inspector must be courteous and should be tact- 
ful in all his relations to cases of smallpox, the same as a doc- 
tor should be in his private practice. He should be a complete 
master of the situation, able to dispose of complications and 
duties as they arise, in a proper manner. It should not be bur- 
densome to do so, for the reward is always present, the con- 
sciousness that it is life-saving work. Use discretion and se- 
cure compliance with the ordinance without force. This can 
almost always be done, but if necessary the police power can be 
used to enforce compliance with the law. 

"You should read and familiarize yourself with the City Or- 
dinance relating to sanitary work/' 
Vaccination. 

All preventive measures against smallpox are insignificant Value of vac- 
by the side of vaccination. If vaccination and re-vaccination were cmation 
properly performed and universally applied, the consideration 
of palliative and curative remedies would be superfluous. Vac- 
cination, with re-vaccination until the susceptibility to vaccine 
is exhausted, is an absolute protection against an attack of small- 
pox. A person thus vaccinated cannot contract smallpox. 



578 



SMALLPOX 



Effects 



Age and peri- 
ods of revac- 
cination 



A successful vaccination is characterized by vesiculation, 
pustulation, mild and limited inflammatory area with febrile 
reaction. In about twenty days from the beginning of the 
vesicle the resulting scab comes off. This leaves a scar which 
is typical, if there is no extraneous infection to cause inflamma- 
tion and sloughing. Such a vaccination can be secured by using 
potent lymph which has been freed from pathogenic germs by 
mixture with glycerine. This vaccination is protective against 
smallpox for about ten years. Sometimes this single vaccina- 
tion is protective for a lifetime, but occasionally a person is 
again susceptible to a mild attack of smallpox in a little less 
than ten years from date of vaccination. 

Every child should be vaccinated before the age of six 
months, and again in from seven to ten years. The operation 
should be repeated at periods of seven to ten years during life 
to make sure the protective influence has not been partially 
exhausted. If it fails to take it gives no inconvenience and 
does no harm. If it takes, it proves that the former vaccina- 
tion is not now, at the time of the retrial, wholly protective. 
All persons not having had smallpox are susceptible to vaccinia 
at least once. Eepeat the operation a dozen times if necessary 
to secure a successful result. The statement that this or that 
one is insusceptible to vaccinia — and consequently .smallpox — 
is responsible for many deaths from smallpox. The writer saw 
a cashier of a bank die of hemorrhagic smallpox a few years 
ago, who had been vaccinated five times — all failures. His 
physician told him he was insusceptible to vaccinia and need 
not fear smallpox, — a bit of false professional advice which cost 
a useful man his life at the age of 33 years. Inert lymph or 
faulty technique are responsible for most failures to secure a 
typical result. 

To perform the operation, sterilize the skin, preferably of the 
left arm — the right if the subject is left-handed. If the subject 
is a girl, a place high up on the arm near the shoulder; in men 
and boys at the insertion of the deltoid. Use glycerinated 
lymph and blow the lymph — not with the breath, but with the 
rubber bulb furnished for the purpose — on the disinfected skin 
before scarifying. Take the arm in the hand, and by pressure 
make the skin on the upper aspect a little tense. Then with 
the point of a dull, sterilized needle, go right through the drop 
of lymph, and with slight pressure, irritate and abrade the skin, 
covered by the drop, until it is red. Lay bare the cutis vera, 
but do not bring blood. You cannot always avoid bringing a 
little blood, but if a dull needle is used with slight pressure 



SMALLPOX 579 

blood will seldom flow. Scarify a space exactly one-eighth of an 
inch in diameter, this size: 4 

Make but one mark. Vaccinia is a systemic disease, and a Technique of 
single inoculation should be as efficacious in producing vaccinia 
as a greater number, unless there is an interval of time between 
the vaccinations. The observations that have been made upon 
subjects with one, two, three or more scars, have led many to 
believe that two or more scars are more protective from small- 
pox than one scar. This I believe applies only where a period 
of time elapses between the production of a first, second and 
third scar. A dull needle is the best instrument to use for 
vaccinating; it is cheap, easily sterilized in a gas jet or flame 
of a lighted match, and does not terrorize children. 

For convenience and clearness of understanding the cura- 
tive and palliative treatment of smallpox, it is best to consider 
the treatment as applied to the disease in its various stages — 
the incubative stage, the invasion stage, the eruptive stage and 
the stage of desiccation. 

THE INCUBATIVE STAGE. 

During this stage nothing is known to be of any benefit in Treatment of 
staying the disease after the reception of the infection into the stag-e nCUbatlVe 
blood, except vaccination, and that is of use only when applied 
during the first three days after receiving the infective agent. 
Vaccination will always prevent the disease if applied the first 
two days after exposure to the same, and will, in the great ma- 
jority of cases, prevent the disease when made use of on the 
third day after exposure to the smallpox infection. On the 
fourth and fifth days, perhaps the sixth, if tried, vaccina- 
tion will modify the disease, but after this time it has no modify- 
ing effect. 

A person exposed to smallpox should be vaccinated without 
delay. Repeat the operation the next day, and continue to vac- 
cinate daily until you are sure one of the vaccinations is begin- 
ning to "take," then stop. By this method it is almost a cer- 
tainty that you will secure a successful vaccination in the first 
three days' period, which insures the safety of the individual. 
When this practice is followed three or four vesicles may and 
often do result, but it saves life. If one vaccinates the first day 
of exposure, and waits to see if it "takes" before making another 
attempt, it results in the case of failure in losing all chance of 
preventing the disease. In other words, we have three days 
or chances to prevent the disease, and use but one. It is safer 
to make good use of the three chances. 

If vaccination is not resorted to early enough to prevent 



580 



SMALLPOX 



Sustaining ef- 
forts 



Treatment of 
the stage of 
invasion 



the disease, the victim must meet one of the most formidable and 
deadly foes known to the human race. Anything that can be 
done to increase the power of resistance to disease should be 
done at this stage. 

Dr. I. D. Rawlings, of the Chicago Isolation Hospital, has 
practised and advocates the placing of a person known to be 
exposed to smallpox in training for the fight with the approach- 
ing disease. He forbids alcohol in any form — the popular 
prophylactic with the laity — and places the subjects upon a 
good nourishing diet; keeps them in the open air as much as 
possible, and gives them regular and helpful exercise. He pro- 
motes excretion by baths and such laxatives as may be needed. 
He aims to promote bodily vigor, and thus increase the resist- 
ing power against disease. The subject should be kept cheerful 
and hopeful by encouraging and reassuring advice. This is 
rational treatment. It fortifies the body against the exhausting 
influence of this truly frightful disease. Nothing further can 
be done during this incubative stage. 

THE STAGE OF INVASION. 

This stage — which usually lasts three days — exceptionally 
only two days, and occasionally prolonged to four days — is the 
initial febrile stage. All we can do in this period is to palliate 
distressing symptoms and promote comfort. For excessive fever, 
cool sponge baths, and ice to the head if the headache is severe. 
Some of the coal-tar preparations, as acetanilid, may relieve 
backache and headache. To aid excretion and help to reduce 
fever, liquor ammoniae, acetatis, two teaspoonfuls every two 
hours, is of some service. To relieve pain, codeine may be used. 
Convulsions in children in the beginning are best treated by 
hot baths, and, if persistent, chloral, well diluted with water to 
avoid irritating the stomach. The early pain in muscles and 
back is relieved by two or three capsules of acetanilid, grains 
iii; monobromate of camphor, grains ii, and citrate of caffein, 
grains i. Codeine may be added to this capsule if the pain is 
excessive. 

At this stage the nourishment should be cold milk, ice cream 
and water. 

As the stage of eruption approaches all the painful symp- 
toms become intensified. Fever high, frequently 106° F., severe 
backache, intense headache, nausea, anorexia and sometimes de- 
lirium. To relieve these distressing symptoms, morphine given 
hypodermically is the most effective, one-eighth of a grain, and 
repeat the dose in an hour or two if needed. The ice cap and 
morphine often relieve delirium. Bromides and chloral given 



SMALLPOX 581 

for delirium are irritating to the sensitive stomach, while mor- 
phine is better borne. Cold sponge baths should be continued 
when the temperature is high, and if the patient is able to stand 
the exertion, and he usually is, he can be placed in a tub for a 
cold bath. 

On the evening of the third or morning of the fourth day 
the eruption on the skin appears, and all these distressing symp- 
toms, as a rule, cease. The headache and backache are gone and 
fever usually disappears. In severe cases the temperature may 
remain up for twenty-four or thirty-six hours before dropping 
to the normal. Exceptionally, the temperature may be con- 
tinuous throughout the course of the disease. 

THE ERUPTIVE STAGE. 

As the eruption appears little treatment will be needed for Treatment of 
a few days. The patient feels well, and the majority at this * ne eruptive 
time will get up and walk or sit up. This is the period in the 
disease when the patient will walk out and visit the doctor's 
office, or take a trip on the railroad to visit friends. He should 
be kept in bed and given nourishing food during the several 
days of comparative comfort he will now experience. At this 
time the appetite is quite good, and the patient can take with 
benefit to himself a pretty generous diet. Semi-solids can be 
given freely, such as oat-meal and cream, milk-toast, custard, 
soft boiled eggs, rice and baked apples. The mild cases never 
having fever after the invasion stage, can eat steak, chicken, 
fish, oysters and vegetables. 

About the second day of the eruption the papules appear 
vesicular and continue to grow larger and fill with serum until 
about the fifth day, when the contents turn white or milky in 
color. This is the end of the vesicular and the beginning of the 
pustular period. There is almost always absence of fever up 
to the beginning of the pustular period, and during the papular 
and vesicular periods the treatment, aside from feeding, is 
local — principally directed to the throat and mouth. The ves- 
icles in the mouth and throat, covered with the thin mucous Mouth and 
membrane, rupture early and leave superficial, sensitive and throat 
painful ulcers. If these lesions are treated promptly they will 
heal in advance of the skin eruptions. This is important, be- 
cause the patient then can and will take nourishment much bet- 
ter in the later and more severe stage of the disease. Any good 
antiseptic mouth wash or gargle can be used. Dobell's solution 
makes a good one. To this a little cocaine can be added if the 
mouth and throat are very sensitive and sore. This gargle can 
be used frequently. An atomizer can be used to throw the solu- 
tion deep into the pharynx. 



582 



SMALLPOX 



Conjunctiva 



Cannot abort 
pustules 



Critical pe- 
riod 



Conjunctivitis, which is frequently noted, is due to the pres- 
ence of one or more vesicles on the inner surface of the eye- 
lids. It is best not to open these vesicles, as the rough edges of 
the incision irritate the conjunctiva more than does the unbroken 
vesicle. Use in the eye freely a saturated solution of boric acid 
and firmly apply a compress and bandage to prevent use and 
movement of the eye. Movements of the eye increase the irrita- 
tion, .but the compress must be removed hourly, and the boric 
acid solution instilled into the eye. The vesicle may form upon 
the cornea, in such case there is danger of perforation and de- 
struction of sight from deep ulceration. By carrying out the 
above treatment for conjunctivitis much can be done to lessen 
the dangers from ulceration of the cornea. 

In this early stage all attempts to avert the approaching 
pustular stage have been futile. In our experience none of the 
numerous remedies recommended for internal administration, 
with a view to aborting the lesions, have in the slightest degree 
modified the course of the vesicle or pustule. Puncturing the 
vesicle and cauterizing with a view to lessen the pitting, is a 
doubtful procedure. Injecting the vesicle with 1 to 200 bichlo- 
ride of mercury solution, which has been advocated, proves to 
be useless. All kinds of applications to the skin have been use- 
less in our hands in lessening destruction of tissue. We wrap- 
ped a hand and arm with a thick covering of Fuller's earth, 
glycerine and oxychlorine, and kept it covered without disturb- 
ance from the beginning of the papular to the middle of the 
pustular period. No local treatment was given the other hand 
and arm. "When the dressing was removed it was found the 
lesions had gone on in their development the same in the arm 
treated as in the one receiving no treatment. Here also there 
was a complete exclusion of actinic rays of light, which has 
been lauded as capable of preventing the development of pus- 
tules. Of the red light treatment we will speak farther on. 

From the fifth day of the eruption on to the eleventh or 
twelfth day is the suppurative or pustular period of the eruptive 
stage. This is the period in which the majority of deaths occur. 
It is the time when the physician and nurse are most needed. 
Much can now be done for the comfort and safety of the pa- 
tient. Unremitting care and watchfulness on the part of the 
doctor and nurse will pilot to recovery through this distressing 
period many cases which appear hopeless. 

At the beginning of this period, in severe cases, the fever 
returns. This is probably a septic fever. There is an inflam- 
matory area about the pustule and much swelling. Burning and 
itching comes to torment the sufferer. The condition is simi- 



SMALLPOX 583 

lar to that of a man affected with thousands of small boils, upon 
a large number of which he must lay his whole weight. The 
torture is extreme. In the confluent form the condition is 
somewhat similar to an extensive burn of the second degree. 

The indications for treatment during the pustular period 
of smallpox are : 

1st. To allay pain and prevent shock and exhaustion. 

2d. To support the patient. 

3d. To hasten desiccation. 

4th. To combat toxemia. 

5th. To treat complications. 

Owing to the inflammatory condition about the pustules, the 
pain and distress of body at this period is very great. Fever, 
sleeplessness and often delirium fast exhaust the patient's 
strength. At this time bromide and chloral have been given to 
relieve pain and induce sleep. These drugs are not well borne, 
nor are they efficient for the purpose of relief of the condition 
present. 

The painful period of acute inflammatory condition of the 
skin lasts usually from the evening of the sixth day to the 
morning of the ninth, in severe cases a day or two longer. Dur- 
ing this time nothing gives so much relief from pain, itching, 
burning, sleeplessness and delirium as morphia, one-fourth 
grain, repeated if need be every four hours. If a larger dose 
is necessary to secure results, give it. It is well borne and affords 
sleep and comfort. If there is any pre-existing nephritis, mor- 
phia should be used cautiously, if at all. 

Nourishment must be administered, though there may be 
anorexia. A liberal quantity of milk, warm or cold as suits the 
patient, and ice cream are allowable. If the patient does not 
retain these, try milk with lime water, milk-punch, egg-nog and 
kumyss. If all food is rejected feeding by the rectum should 
be restorted to. In support of patient tonics and stimulants 
must be used, as indicated by the condition of the pulse and 
temperature. Strychnia should be given as early as the time 
when the pulse shows weakness. Begin with the one-fortieth 
of a grain every four hours, and increase to one-thirtieth grain, 
given with the same frequency. Brandy should be given for 
five or six days during the suppurative period, and longer if 
the patient is absorbing pus from the surface. Alcohol is un- 
doubtedly valuable in the treatment of septic cases and those who 
were addicted to drink before the attack. Tincture of the chlo- 
ride of iron and quinia are useful also in combating toxemia. 
Antistreptococcus serum was abandoned by us as useless after 
a fair trial. 



584 SMALLPOX 

The cases of true hemorrhagic smallpox are practically hope- 
less. They all die in six, or at longest seven, days. I have 
seen but one live to the seventh day. The same supporting 
treatment given above applies to these cases. Ergot, adrenalin 
and antistreptococcus serum fail to aid, though they have their 
advocates. 

Local applications during the pustular period, that have 
been so extensively used, I do not approve of. To allay itching 
during the vesicular and pustular periods, water with menthol 
can be used, and sponging for cleanliness and reducing fever, 
but this readily dries and does retard desiccation. The 
smallpox lesion in its life history is like that resulting from 
vaccination. The natural history of the lesion is to fill with 
serum, turn pustular, dry up and scale off. Nothing should be 
done to retard this process. The application of continuous 
baths, poultices, plasters, oils or salves of any kind hinders desic- 
cation. We do not use these applications on a vaccination before 
desiccation, and why should we try them in the treatment of 
smallpox ? 

The mild cases are best treated by arranging so that their 
bodies are exposed to the sunlight and air. This hastens the 
drying-up process and shortens the period of pustulation. This 
treatment I would not advise for confluent cases with secondary 
fever in warm weather, as the heat of the sun adds to the dis- 
comfort, but in the discrete cases it is not uncomfortable and 
I believe it shortens the course of the skin lesions. Even the 
patients in the wards notice and remark about those near 
the windows recovering more speedily than those farther from 
the windows and sun's rays. 

From January 1, 1899 to January 1, 1903, there were treated 
in the Chicago Isolation Hospital 690 cases of smallpox, mostly 
of the mild type. They were placed in the sunlight as much as 
possible. The death rate was but 1.6 per cent. — a better showing 
than that recorded under the so-called Finsen ray or red light 
treatment, — the exclusion of the actinic rays of light by means of 
ruby red window glass. 

From January 1, 1903, to January 1, 1906, 1,289 cases were 
treated in the same hospital with a death rate of 10.5 per cent. 
The disease had changed to the severe type. This is a low 
death rate, considering the severe type of the disease. These 
patients, with the exception of about seventy in the red light 
ward, were given plenty of light and air in wards with large 
windows on both sides and one end. About seventy of these 
patients were put in a ward from which the actinic rays were 
rigidly excluded. This red light treatment not only proved 



SMALLPOX 585 

worthless, but was harmful. The red light gives patients in 
delirium the impression often that the house is on fire. Pinsen 
claimed that this treatment, if begun the first day of the erup- 
tion, would prevent the formation of pus. In no instance in our 
experience (and we gave it thorough trial) did the treatment 
in any degree modify the course of the disease. The red light 
treatment for smallpox cannot be recommended. 

As the pustular period advances, the lesions rupture from 
the weight of the body, and the bed sheets stick to the raw 
surface of the lesions. The sheets should be dusted with a pow- 
der composed of boric acid and subgallate of bismuth. Sheets 
must be changed several times daily when the pustules begin to 
break down. Warn patients against scratching the face. 
Adults can be influenced not to scratch the lesions, but children 
cannot resist the itching, and should have their hands enveloped 
in cotton covered by sterile gauze. This will prevent scratch- 
ing. If the itching cannot be resisted, it is better to delay 
desiccation by applying carbolized vaseline 3 per cent., to which 
is added 2 per cent, menthol. Or oxide of zinc ointment, to 
which is added one drachm of campho-phenique to the ounce, 
and 2 per cent of menthol. If the pustules run together and 
become large blebs filled with pus, resembling the blisters from 
burns, the contents may be let out by incision and the dusting 
powder freely applied. This condition is often seen on the 
hands and wrists. 

THE STAGE OF DESICCATION. 

When the pustules are dried, forming scales, the patient Treatment of 

is readv for antiseptic baths, which loosen the scabs and dis- sta S e of desic- 
cation 
infect the surface of the body. The baths found most efficacious 

are bichloride of mercury 1 part to 1000 of water; and equally 
as good permanganate of potash enough to color the water a 
light pink. Then the protecting salves can be freely applied. 
As all pustules are dried now, salves will soften and hasten 
desiccation. Nourishment should now be given freely. Semi- 
solid diet, and in a few days solid food, can be taken with ad- 
vantage. The appetite is usually good, and a substantial diet 
can be given, including meats. If there is anything the patient 
needs now it is food, and he should have three meals daily and 
a lunch between meals. This is the stage when abscesses, boils, 
local surface infections, impetigo, erysipelas and gangrene are 
found, though gangrene of the scrotum has occurred in the pus- 
tular period. All complications of this kind should be treated 
the same as vvhen encountered unaccompanied with smallpox. 
Pneumonia, bronchitis, pleurisy, laryngitis and nephritis may 
occur. The diet must be restricted in case of nephritis. 



586 YELLOW FEVER 

In mild cases no "pitting" remains after recovery. In the 
severe cases there is no treatment which we have tried that will 
prevent pitting. Smallpox, like other morbid processes, is a' 
disease of degree. Some will have small pustules with a com- 
paratively mild inflammatory manifestation. Some cases wiD 
even abort in the papular or vesicular period and escape the 
inflammation of the pustular period. If the pustules are large 
and well filled with pus, and if the epidermis is thick and tena- 
cious, the pus will be held down under the pressure until the 
inflammation extends through the cutis vera. Destruction of 
skin, with "pitting" is the result. 

To summarize: Smallpox is absolutely preventable by vac- 
cination. 

There is no known medicine which in any way modifies the 
disease once it is well started. 

The treatment consists in intelligent nursing and the use 
of such palliative and supporting remedies as are known to give 
and conserve strength. 



YELLOW FEVER. 
(By Dr. Albert J. Mayer and Dr. Urban Maes, New Orleans, La.) 

In yellow fever we are to-day, as with many other diseases, 
without a specific. The treatment is entirely symptomatic. In 
the antitoxin of Sanarelli, discovered in 1895, and published in 
1897, it was hoped that a specific had been found, but experience 
showed its insufficiency. 

In order to intelligently treat yellow fever symptomatically 
it is necessary to touch briefly the various phases of the pathology 
of the disease as they arise. Primarily, we must remember that 
yellow fever is an acute, infectious, febrile disease caused by 
an, as yet, unknown organism. The toxins of this organism, 
circulating in the blood, have certain deleterious effects on the 
human economy, briefly, as follows: 

1. They act as a medullary poison, exerting an early in- 
fluence on the vomiting centers. (This symptom is partially due 
to the capillary stasis in the stomach with mucous and sub- 
mucous hemorrhages.) 

2. They produce vaso-motor paresis, hemolysis and disinte- 
gration of the capillary walls by fatty degeneration, which is 
part of the general steatosis. 

3. They cause pathological changes (fatty degeneration) in 
the liver and kidneys, characterized by jaundice and usually by 
an acute desquamative nephritis. 



YELLOW FEVER 587 

At the first appearance of the symptoms of the disease the Hygiene 
patient must be put to bed. Rest, both mental and physical, is 
an absolute requirement. The patient must not be allowed to 
raise his head off the pillow. Defecation and urination must be 
performed in the recumbent posture and the supply of fluids 
should be administered by means of a tube or feeding cup. The 
best observers are unanimous in agreeing that these statements 
are to be taken in their most literal manner and the physician 
cannot afford to deviate from them in the slightest particular 
from the first moment of attack. 

After being put to bed the patient is clad in the lightest of 
garments so arranged that in order to sponge him it will be un- 
necessary to put him to the slightest exertion. A tepid cleans- 
ing bath is given and the patient is placed in the best lighted 
and ventilated room in the house. Measures of hydrotherapy 
which may later become necessary must be done with the utmost 
gentleness, in fact some observers go so far as to claim that yel- 
low fever being a self -limited disease it is better to ignore the 
pyrexia on account of the accompanying disturbance of bath- 
ing. They believe that the pyrexia is far less dangerous than 
the moving of the patient. We think, however, that a certain 
amount of personal cleanliness adds to the comfort of the pa- 
tient and does much towards hastening convalescence. 

A mouth wash of some alkaline antiseptic solution as chlorate 
of potassium is of service in diminishing the tendency towards 
gingival hemorrhage besides alleviating the bad taste. Enemata 
of soap suds and water should be given every day or every other 
day according to indications, but care must be taken not to irri- 
tate the rectum as it may be our sole reliance for sustaining and 
treating the patient. 

From time immemorial the initial measure of treatment which The foot bath 
has stamped itself most emphatically upon the minds of the prac- 
titioners in the localities subject to the invasion of "Yellow 
Jack" has been the mustard foot-bath or the foot-bath a la 
Creole. 

A foot-tub is partially filled with warm water to which is 
added a pound of freshly ground mustard dissolved in cold 
water. This tub is placed in the bed ; the feet of the patient are 
then immersed. The patient and tub are covered with two or 
three woolen blankets. Every three or four minutes a pint of 
almost boiling water is added to the bath, the feet and legs of 
the patient being rubbed rather vigorously. The sudorific effect 
of the bath must be kept up for at least ten minutes and its 
effects aided by the giving of hot aromatic drinks, hot lemonades 
or teas. 



588 YELLOW FEVER 

This has been in such universal use in New Orleans in 
the epidemics of '53, '65, '78, '97, that a physician is rarely 
called to see a case where this step has not been taken by some 
member of the household, and supplemented by wrapping in 
blankets and the administration of some hot, aromatic drink to 
serve as a diaphoretic and diuretic. There is no doubt that in 
its present form it is of decided value in relieving the head 
symptoms and the congestive phenomena of the first stage of the 
febrile paroxysm. (Matas.) 

If the case is seen early an initial purge of calomel in small 
doses should be given and followed, if the stomach permits, by 
some saline cathartic. After the first stage of the disease is 
passed and the caplliary stasis becomes marked, with nausea 
present, acting as an index of the congestion of the internal 
organs, it is not advisable to use this routine. The predisposition 
to gastric hemorrhage may be thereby augmented, consequently 
the laxative enema is preferable. 

The cephalalgia and rachialgia are best met by topical ap- 
plications, the ice-bag to the head and the mustard plaster or 
other counter-irritant to the loins. The coal-tar derivatives and 
other sedatives, such as codeine and morphine, are only men- 
tioned in this connection to be condemned. As has already been 
shown the toxins exert such a potent influence on the organs of 
elimination and circulation that it is unwise to tax them further. 

The remedies which have been lauded for the nausea are 
legion. The entire group of anti-emetics, including carbolic acid, 
cerium oxalate, cocaine, creosote and the much vaunted bichloride 
lemonade of Sternberg have proven non-efficacious. The sim- 
plest treatment is the best. "When cracked ice, carbonated drinks 
or iced dry champagne fail to relieve, it is the wisest plan to 
give the stomach absolute rest and supply fluids and other nutri- 
ment by rectal administration. 

That usually ominous sign "black vomit," or gastric hem- 
orrhage, is best met with perchloride of iron. (Guiteras.) This 
writer also claims that in hemorrhages from other mucous mem- 
branes (gingival, intestinal and uterine) this drug has given 
him the best results. His experience with adrenalin has not 
served to recommend its use. Ergot, digitalis and aconite have 
also been recommended but have not given good results. Coun- 
ter-irritation over the stomach, ice-bags, mustard plasters, blis- 
tering with cantharides or the actual cautery, and dry cups are 
of little value. 
Pyrexia Temperature is best controlled by hydrotherapy. The tub 

bath as used in typhoid is never employed in this malady, but 



YELLOW FEVER 589 

sponging and packing are the measures most often resorted to. 
Enemata of cool water can also be used as a means of reducing 
the temperature and stimulating the patient. In addition they 
furnish the body with the fluid so necessary for the dilution and 
the elimination of the poisons of the disease. 

In Las Animas Hospital hydrotherapy was used to the com- 
plete exclusion of drugs, and striking results were obtained. 
Gorgas, of this hospital, says, "Generally when the temperature 
remains above 103° for any length of time I have the patients 
sponged every two hours with cold water." 

Because of the capillary stasis occurring in this disease the 
sponging is best accompanied by mild friction. Ice bags to the 
head and back of the neck are beneficial, insomuch as they are 
useful in the general scheme of hydrotherapy and are grateful 
to the patient. 

Here we again mention the whole group of antipyretic drugs 
to state that while they may have a certain limited field of use- 
fulness they are not to be recommended as a routine. The use 
of the cinchona group has long since been abandoned. 

The most grave condition with which we have to contend is 
complete suppression of urine. This should not be confounded 
with simple retention which can be relieved by catheterization. Anuria 
The possible occurrence of urinary suppression must always be 
borne in mind. Albuminuria, which appears in most cases on 
the third day, should, for safety's sake, be regarded as a fore- 
runner of this condition. Daily examinations of the urine are 
absolutely necessary. A scanty flow with an increasing albu- 
minuria and microscopic findings, indicative of the severity of 
the kidney lesion, calls for energetic measures on the part of the 
attending physician. Once such a state is established, therapeu- 
tics are of little avail ; consequently we should endeavor to fore- 
stall this condition by appropriate measures. 

When the stomach will allow, large draughts of hot or cold 
water, flavored or not, as best suits the patient, are to be given. 
The alkaline waters, such as Vichy (Celestin), Apolinaris and 
White Rock are of great value. The necessity of giving a large 
amount of fluids having been demonstrated, the rectum must be 
resorted to where the nausea proves intractable. Hypodermocly- 
sis and intra-venous infusion with normal saline solution have 
been used but it was the experience of Matas and others in New 
Orleans in '97 that when suppression actualfy existed even this 
was useless. 

The diuretic drugs, more particularly the citrate and acetate 
of potassium combined with the infusion of digitalis, still have 
a more or less deserved reputation in the hands of some practi- 



590 



YELLOW FEVER 



tioners. Their usefulness cannot be doubted in mild cases and 
when employed early in the attack. Dry and wet cups are also 
used. 

There is no disease in which we can less afford to dispense 
with the aid of a competent nurse. The value of her services 
can only be measured in terms of human life. With the innu- 
merable calls that are made upon a physician's time in yellow 
fever stricken communities the necessity of accurately recorded 
observations, especially of pulse, temperature and the organs 
of elimination in each case, are of the highest value. There is no 
doubt that the professional nurse is no small factor in the reduc- 
tion of the mortality of yellow fever. To quote from Osier, 
"Careful nursing and a symptomatic plan of treatment give 
the best results. ' ' 

Stimulants After the initial fever of forty-two to seventy-two hours' 

duration we have a secondary rise and it is in, or following, this 
stage that the patient is most often brought face to face with 
death. Stimulation with strychnia in doses of one-sixtieth to 
one-thirtieth grain hypodermically every three to four hours, 
supplemented by mild alcoholics, preferably in the form of iced 
champagne and Ducro's elixir, panopepton, and the digested 
beef essences, are indicated at the first signs of failing circula- 
tion. In this secondary fever, called the fever of auto-intoxica- 
tion by Sanarelli, various intestinal antiseptics, more particu- 
larly salol, were faithfully tried in Havana but, as shown by 
Gorgas and Guiteras at Las Animas in 1900, they are of doubt- 
ful value. 

Diet We have already spoken of the gastric irritability and what 

its persistence means. All physicians are agreed, and it may 
be laid down as a dogmatic fact, that during the first four days 
of the disease no nourishment should be given except water 
which may be supplied to the point of toleration. By the fifth 
day the crisis has usually passed, and we may then begin with 
milk in small quantities, plain, or with the addition of lime 
water. The quantity of nourishment is gradually increased with 
the addition of broths and strained soups. This liquid regimen 
should be continued until the beginning of the second week, 
when the patient may be allowed to sit up and begin a gradually 
increasing diet. 

Prophylaxis While the present prophylaxis of yellow fever has only been 

established since 1900, Finlay of Havana, as far back as 1881, 
had already given up the fomites theory and had begun to sus- 
pect that some blood-sucking insect acted as the intermediary 
host of the vellow fever organism. 



YELLOW FEVER 591 

The peculiarities of the stegomyia fasciata, its methods of 
feeding, its universal presence in the zones liable to epidemics 
and its hibernation coincident with the disappearance of the 
disease in the zones of accidental infection, led him to direct his 
investigations towards that particular mosquito. In 1898 he 
announced the following conclusions, on which was based the 
work of later investigators and upon which rests our present 
system of scientific control: 

1. That the germ of yellow fever is only pathogenic to 
human beings when introduced by inoculation. 

2. That the regular process by which the inoculation of 
the germ is accomplished in Nature, is through the bites of the 
•culex mosquito (stegomyia fasciata), the insect having previously 
become contaminated through the act of biting a yellow fever 
patient within the first five days of his attack. 

3. That although the bites of a recently contaminated mos- 
quito can produce at most only a very mild attack of yellow 
fever, or simply confer patent immunity without eliciting any 
obvious pathogenic manifestations, the bites of the same insect 
when its contamination dates back from several days or weeks, 
might produce severe or fatal attacks. 

4. That the yellow fever mosquitoes after they have once 
become contaminated, retain the power of inoculating the disease 
during the rest of their lives. Carter's work* was to the effect: 

1. That yellow fever was a house disease. 

2. That a house infected with yellow fever was not infective 
until a certain period of time had elapsed. He fixed this period 
at from ten to twelve days. It remained for the United States 
Army Commission under Dr. Walter Reed, consisting of Reed, 
Lazier, Carroll and Agramonte, to show conclusively that the 
blame belonged to the female stegomyia fasciata, thus confirming 
Finlay. Later commissions, notably those of the Liverpool 
School of Tropical Medicine, the Hamburg School of Tropical 
Medicine, working parties of the United States Public Health 
and Marine Hospital Service, and independent investigators, 
especially Guiteras, working along these lines further fixed upon 
the stegomyia fasciata as the sole agent capable of transmitting 
the disease. 

Prior to 1901 sanitarians devoted their efforts in stamping 
out the disease in accordance with the theory of fomites, but the 
labors of the above mentioned scientists, and the work of Gorgas 



*New Orleans Medical and Surgical Journal, 1900. 



592 YELLOW FEVER 

in eradicating the disease from Havana, its perennial home, 
showed clearly that the prophylaxis of the yellow fever lay in 
the destruction of the stegomyia fasciata, for in the words of 
Carroll, "No mosquitoes, no yellow fever." 
Prophylaxis Yellow fever, distinctly an acute, infectious disease, is trans- 

mitted from individual to individual, as far as we know, by 
the agency of the female stegomyia fasciata, aud therefor it can 
be eradicated as an epidemic by the destruction of this mosquito, 
and the individual can be safeguarded by being protected from 
the bites of an infected insect. 

In instituting prophylactic measures against yellow fever, 
we must bear in mind the following facts: 

1. That the yellow fever patient is capable of infecting the 
stegomyia fasciata during the first three days of the disease only. 
(The yellow fever cadaver is not infectious.) 

2. At least twelve days must elapse before the bite of an 
infected mosquito can transfer the active poison to a non- 
immune. 

3. The period of incubation is from forty-one hours to live 
days and seventeen hours. (United States Army Commission.) 

4. No direct transmission from patient to patient has ever 
been recorded except by experimental inoculation. 

5. The infectious life of the stegomyia fasciata ranges from 
twelve days to fifty-seven days (Reed), to one hundred and ten 
days (Guiteras). 

In safeguarding the non-immune, it is obvious from the 
foregoing facts that the mosquito must be prevented from at- 
tacking the patient during the first three days of the disease. 
This is best accomplished by placing the sick person in a care- 
fully screened room, which has been freed from mosquitoes by 
fumigation, and under a mosquito netting which has at least 
18 meshes to the inch. Further, the entire house, except the 
sick room, must be fumigated within twelve days of the onset 
of the fever, in order to destroy any stegomyias that may have 
become infected prior to the recognition of the disease. And 
finally, the entire house, including the sick-room, must be again 
fumigated after the recovery of the patient. When this pro- 
cedure is carried out, the danger to susceptible persons in the 
house and neighborhood is practically nil. This was the method 
pursued successfully in Havana by Gorgas, and his successors, 
except where it was possible, under a military regime, to re- 
move the patient in a screened conveyance to Las Animas Hos- 
pital. In cases of this nature, all the mosquitoes in the infected 
house were immediately destroyed by fumigation with pyre- 
thrum. The evolution of yellow fever prophylaxis as practiced 



YELLOW FEVER 593 

on a large scale was best depicted in controlling the spread of 
the disease after it had gained a firm footing in New Orleans in 
1905. The successful and remorseless war raged, not against 
the invisible and unknown foe of former years, but against the 
well-known striped or tiger mosquito, will live forever in the 
annals of preventive medicine and sanitary science, as the most 
brilliant achievement in the history of any nation. 

In all cases where possible the following routine was fol- 
lowed: A room adjoining that of the patient was carefully 
screened and sealed; it was then fumigated with sulphur (two 
pounds to the thousand cubic feet), and thoroughly aired. The 
patient was then transferred to this room and the remainder of 
the house fumigated in the same manner. In cases seen after the 
first three days of the disease the patient was transferred to 
another room if possible, and the room fumigated in order to 
kill the infected mosquitoes before they could get out to deposit 
their eggs after their essential meal of blood. This killing off of 
the infected mosquitoes in the room itself, and the neighboring 
buildings is the sine qua non in combating a yellow fever epi- 
demic. 

Unsuspected cases, and cases not easily recognized, as are 
not uncommon among children, sometimes furnish hidden foci 
which remain as a source of infection to the entire vicinity. In 
instances of this sort, wholesale mosquito destruction becomes im- 
perative. The breeding places must be ruthlessly destroyed. 

Guiteras, the greatest living student of yellow fever, recog- 
nizes three areas of infection. phylxSs Pr °" 

The focal zone in which the disease is never absent. This 
formerly included Havana, Rio, Vera Cruz, and the ports of the 
Spanish-American main. Thanks to the labors of the sanitary 
workers we can eliminate two of these, Havana and Vera Cruz. 

2. The peri-focal zone or regions of periodic epidemics. This 
zone includes the port of the tropical Atlantic in America and 
Africa. 

3. The zone of accidental infection between the parallels of 
35° South and 45° North. The peri-focal and the zones of 
accidental infection can be protected from the introduction of 
the disease by efficient quarantine regulations preventing the 
ingress of infected persons from infected ports, and establishing 
such a period of detention that the disease may have time to de- 
velop before suspected non-immunes are allowed to enter a non- 
infected port. 






594 



SYPHILIS. 

(By Dr. F. Kreissl, Chicago.) 
The treatment of syphilis is both a local and a constitutional 



Local treatment 



Excision of 
chancre 



Cauterization 
of chancre 



Antiseptics lo- 
cally 



(1) With local treatment we attempt to destroy, or at least 
weaken, the specific virus wherever its initial presence is evi- 
denced by pathological lesions. This may be accomplished by 
cauterization or by excision of the venereal sore. 

According to Fournier excision gives an average of one suc- 
cess in five cases, the success depending upon the length of time 
between the appearance of the chancre and its surgical removal. 
Even if failure as an abortive procedure occurs, the excision 
of the chancre certainly renders the subsequent course of the dis- 
ease much milder. 

The cauterization of the venereal ulcer is less effectual as an 
abortive means. In fact, I do not believe that such is possible, 
but it unquestionably lessens the severity of the subsequent 
symptoms. Neither procedure is indicated when the adjoining 
lymphatics are already involved. 

The venereal ulcer should be treated on general surgical 
principles like any other wound. We employ mild antiseptic so- 
lutions like two per cent, carbolic acid, or 1 in 3000 bichloride 
of mercury for cleansing, followed by a thin layer of dusting 
powder on the dried surface. Most effective, but obnoxious on 
account of its odor, is iodoform used pure or with equal parts 
of boric acid. Instead of this dermatol, iodol, or europhen may 
be employed. Gauze compresses saturated with any of the above 
solutions may be applied several times a day to chancres with 
sluggish granulations showing little tendency to heal. Gan- 
grenous or phagedenic chancres require cauterizing with the 
Paquelin, followed by the application of the nitrate of silver 
pencil, or a ten per cent zinc chloride solution, or nitric acid. 
Sometimes cauterization will have to be preceded by a thorough 
curettage of the ulcer, both procedures requiring a general an- 
esthetic. As soon as the ulcer has a healthy appearance and 
one does not wish to commence with the constitutional treat- 
ment, it should be covered with Unna's mercury plaster mull, 
to be changed once or twice a day, depending on the amount of 
wound secretion. This plaster mull is applied even after the 
sore has healed, as long as the induration is noticeable. If 
phymosis has been caused by chancre, and if the latter is not ac- 
cessible to local treatment, we expose the ulcer by circumcision 
or by a dorsal division of the prepuce. 



SYPHILIS 595 

Chancres in the vagina and on the cervix are exposed by a 
speculum and treated in the same manner as elsewhere, but the 
mercury is applied as ointment on a gauze tampon. The latter 
has to be omitted during pregnancy and in its stead vaginal 
balls of equal parts of cocoa butter and mercury ointment are 
inserted. Initial lesions in the mouth and on the tonsils require 
daily applications of a ten per cent, solution of bichloride of 
mercury in alcohol or ether. 

Venereal papillomata yield to the daily application of re- 



Resorcin 9.0 

Sacchar. 1.0 

Sig. Dusting powder. 



Or 



9 

Resorcin 5.0 

Aqua distil. 100.0 

Sig. Apply on gauze sponge. 



Or 



9 

Acid lactic 

Ether sulph. aa 10.00 

Hydrarg. bichlor. cor. 0.10 

Sig. Apply with a brush once a day. 

Very effective because one application usually suffices is: 

Plumb, causticum 

Solut. Kalin caustic (30 %) aa 7.50 

Lithargyri 0.25 

Sig. Apply with the point of a wooden stick. 

This mixture is applied to the whole growth and the healthy 
skin protected during the application. Papillomata resisting 
this treatment are curetted and cauterized with Paquelin. The 
condylomata around the anus usually disappear under calomel 
dusting powder and an isolating gauze pad. 



596 SYPHILIS 

Indurated lymph glands are covered with, mercury plaster 
mull. 
Suppurations Suppurating glands have to be opened and treated in the 

following manner: After shaving and cleansing the region in 
the customary way and anesthetizing with ethyl-chlorid, an in- 
cision is made in the long axis of the bubo and carried down to 
the pus cavity; the latter is not only exposed, but its contents 
are squeezed out with the fingers by rather hard pressure all 
over the region. This is kept up for a minute or so until the 
fluid becomes free from pus and appears sanguinolent. The 
abscess cavity should not be irrigated, only the edge of the 
wound cleansed with boiling hot water. Now the wound is 
closed by an interrupted horsehair suture. No drainage is nec- 
essary. The region is cleansed with hot sponges once more and 
a gauze collodion dressing applied. Over this comes a com- 
pressing pad and bandage to be maintained for several days. 
The sutures are removed after ten days, at which time, if at all, 
healing by primary union has occurred. 

Onychia and paronychia require a daily local bath in bi- 
chloride of mercury solution in the strength of 1 in 2000, fol- 
lowed by a dusting with 



i* 



Calomel 

Talcum venet. 

Sig. Dusting powder. 



2.0 
20.0 



Gummata 



(iummata which are not yet liquefied or not exulcerated are 
often absorbed by tincture of iodine or mercury plaster mull, or 
a ten per cent, calomel traumaticin applied daily. 



Calomel 5.00 

Traumaticini 20.0 

Sig. Shake well, apply with brush. 



Constitutional 
treatment 



An exulcerated gumma is treated like a phagedena ulcer; 
mucous patches in the mouth like ulceration therein. 

The constitutional treatment should be commenced as soon as 
the syphilitic character of the ulcer is with certainty established 
and the healing process retarded and in all secondary and ter- 
tiary manifestations of the disease. The sovereign remedy is 
mercury. It is administered: 1. By the mouth. 2. By in- 
unction. 3. By injection. 



SYPHILIS 597 

Preceding the treatment attention should be paid to the con- 
dition of the gastro-intestinal tract, the diet regulated, the urine 
examined and the mouth and teeth put in the best possible con- 
dition. 

By mouth, mercury is given in pills or capsules, but we must Mercury by the 
remember the caustic action of the drug on the intestinal tract. mou 



yrum oxydulatum tannicum is 


very effective. 


Hydrargyrum oxyd. tannic, 


2.50 


Opii p., 


0.25 


Sacch. lact. 


3.50 


Lanolin 


1.25 


M. f. pill— No. 50 




Sig. Four to six pills a day. 





Opium is added when the bowels are very loose. Hydrargy- 
rum oxydulatum tannicum is incompatible with carbonates and 
iodine preparations. 

Equally reliable as the above is 



$ 




Hydrarg. protoiodid. 


1.50 


Decoct, opii aq., 


0.50 


Lanolin 


1.50 


Sacch. lact. 


4.50 


M. f. pill— No. 50. 




Sig. Four to five pills a day. 





The prescription should call for a small number of pills, in 
order that they may be fresh. Those which are kept in stock 
are sometimes very old and get so hard that the gastro-intestinal 
juices are not able to dissolve them; many disappointing results 
are due to this fact. 

Mercury, given by mouth, should be taken immediately after 
a meal. In case of diarrhea its use must be discontinued and 
opium given. If the intestinal irritation recurs after the drug 
is resumed, this mode of treatment must be abandoned and in- 
unction or injections resorted to. More recently cypridol, a 
one per cent, solution of biniodide of mercury in oil, has been 
used. It is given systematically for three weeks in the first three 
months in doses of two capsules, three or four times a day after 
meals. For the following three months the same amount is given 
every alternate fortnight and after that eight days of each suc- 
ceeding month for three consecutive years. The claim is made 



598 



SYPHILIS 



Mercury by in- 
unction 



that it is not as irritating to the gastro-intestinal tract as the 
other preparations of mercury, which limits their value on ac- 
count of the small amount of the drug that can be administered 
by mouth. 

For inunctions unguentum hydrargyri is used, mixed with 
equal parts of unguentum petrolatum. It is dispensed in gelatin 
capsules or in paraffin paper, each containing two to three 
grammes of the ointment for an adult and one-half to one 
gramme for a child. 



9 



Unguenti hydrargyri 
Unguenti petrolati aa 
(Caps, gelatin) paraffin paper No. XII. 
Sig. Use as directed. 



1.50 



Disadvantages 
of inunctions 



Wherever possible easily accessible hairless portions of the 
skin are selected, and each inunction applied to new parts fol- 
lowing a set cycle as, for instance, 

First night — arms and forearms. 

Second night — both sides of chest. 

Third night — the loins. 

Fourth night — the abdomen. 

Fifth night — inner surface of thighs. 

Sixth night — no inunction, warm bath. 

Seventh night — inunction as on first night, etc., etc. 

In this way unnecessary cutaneous irritation is usually avoid- 
ed. (Eczema mercuriale — Folliculitis — Toxic Erythema.) The 
inunction should be made by the patient himself, but if made by 
anyone else rubber gloves should be worn. Each rubbing re- 
quires about twenty minutes, and it is a good plan to rub in 
small portions — about the size of a bean — of the ointment, this 
procedure to be repeated when the skin becomes dry. 

The disadvantages of this mode of treatment are its un- 
cleanliness; the irritating effect on the skin; the time consumed 
by each application; and the impossibility of an exact dosage. 
Most of the mercury contained in the ointment evaporates when 
brought in contact with the living body, the greater part of the 
vapors entering the system through the respiratory organs, the 
smaller part through the skin. This explains why patients 
treated under otherwise identical conditions sometimes are easily 
salivated and at other times do not seem to respond to the treat- 
ment at all. These different observations largely depend on the 
temperature surrounding the body after the inunction. In- 



SYPHILIS 599 

stinctively older syphilologists ordered the inunctions to be made 
in superheated rooms and had the patients wrapped in flannel 
blankets for hours afterwards. 

Instead of the mercurial ointment, mercury plasters or the Mercury pla 
plaster mull spread over large areas of the body may be used ters 
to advantage, especially in children. It is renewed once a week. 



V 




Emplastr. hydrarg. oleinicum 




Emplastr. plumbi olein. 


aa 140.0 


Hydrargy depur. 




for adults 


60.0 


for children 


30.0 


Sig. Plaster 





Another way of administering mercury externally is the Mercury baths 
bichloride of mercury bath, but, in order to be really effective, 
i. e., penetrate through the skin, it has to be given in connection 
with electri kataphoresis, which is accomplished by the electric 
two-cell bath. 

The quantity required for a bath varies from ten to fifteen 
grammes of bichloride of mercury. It is useful in the treatment 
of very young children, and of moist papular, pustular, and ul- 
cerating syphilitic lesions on the skin. 

For the subcutaneous application of mercury soluble and in- Mercury sub- 
soluble preparations are employed. They are injected hypo- cutane °usly 
dermically or intramuscularly. Best known and most generally 
used, among the soluble preparations, is the bichloride of mer- 
cury. It is prescribed in one per cent, to five per cent, solutions 
to which is added sodium chloride, which presents the precipita- 
tion of albuminates of mercury. 



Hydrarg. bichlor. corros 


1.0-5.0 


Natrii chlor. 


1.0-5.0 


Aqua distill. 


100.0 


Sig. Bichloride solution. 





Usually 1 cc, equal to 0.01 of bichloride of mercury, is in- 
jected in the gluteal region daily, or every other day, as the case 
may require. It is well to follow a certain routine in injecting. 
The injection should be given alternately in the left and right 
buttock, in and outside of a vertical line crossing its highest 
elevation, so that the solution is deposited in a new place each 
time. It should be injected slowly in order to avoid painful 



600 SYPHILIS 

bruising and unnecessary destruction of tissue; a slight massage 
following the withdrawal of the needle will spread the fluid 
over a larger area. The syringe may be made entirely of glass 
or of glass with hard rubber trimmings, the needle of platinum- 
iridium — l 1 /^ to 1% inches long and narrow gauged. When 
using shorter needles the fluid is placed too close to the skin, 
causing inflammation, eventually even necrosis; while, when 
longer needles are used, as for intramuscular injections, these 
are followed by extremely painful infiltrations. With needles 
of the above length, I am able to deposit the fluid in the loose 
tissue right over the gluteal muscles, avoiding all these disagree- 
able features. What little pain is experienced ceases soon or is 
shortly checked by the application of heat. ■ The platinum- 
iridium-needle is preferable to a steel needle because the latter 
easily becomes corroded and punctured along its walls, allowing 
the solution to escape through these little holes into tissues close 
to the skin, producing the above inflammations. It is hardly 
necessary to say that the same antiseptic precautions as in or- 
dinary hypodermic injections should be rigidly observed, or to 
mention the yet quite rare possibility of an embolus, due to the 
puncturing of an injection into one of the large gluteal veins. 

Cypridol may also be injected hypodermically like bichloride 
of mercury in the dosis of 0.5 cc, equal to one one hundredth 
grain of the bichloride. The needle used must be of larger size 
on account of the oil passing through it. Otherwise the same 
rules as in bichloride injections apply to its application. 
Lang's "gray Of the insoluble mercury preparations Lang's "gray oil" 

oil " has stood the test of many thousand cases within the last twenty 

years. It is a compound of fat, oil and metallic mercury, dis- 
pensed as a fifty per cent, and a thirty per cent, liquid. The 
former consisting of two parts of mercury and one part each of 
lanolin and vaselin oil. 

Unguent cinereum lanolinat. forte 9.0 

Olei vaselini 3.0 

Sig. Oleum cinerum 50%. 

The fluid is slightly warmed and well shaken before being used. 
The dose for one injection is 0.05 cc, equal to 0.04 metallic mer- 
cury, and is administered in intervals of three days until a de- 
cided improvement in the symptoms becomes apparent, when but 
one injection a week is given and two more injections in an in- 
terval of two weeks after all symptoms have subsided. Rarely 
more than twelve injections are required to accomplish this end. 



SYPHILIS 601 

The oil is deposited in the back about two inches from the 
dorsal spine. The needle is inserted almost parallel to and 
underneath the cutis. If this is observed the injection is almost 
painless and not followed by induration and inflammation. This 
is due to the lack of corrosive properties of the remedy and the 
very small quantity incorporated which precludes bruising or 
•destruction of tissue. Each following injection should be placed 
about two inches from the preceding one. If it is desired to in- 
ject more than 0.05 cc. this should be done in two equal parts 
of 0.05 cc. and in two different places. The advantages of the 
gray oil are, as said before, the small volume required for one 
application, the absence of reactive inflammation and the longer 
remanence of the preparation which establishes a reserve in the 
tissues to draw upon much longer than from soluble mercury 
solutions. But therein lies also the danger of an oversupply in 
the hands of those not familiar with the drug, the disease and 
the symptoms. 

Reviewing the various methods of administering mercury, Comparison of 

we can see the superiority of subcutaneous injections. They m e tnods of 

r J rf using mercury 

permit an exact dosage, guarding in this way against either mer- 
curial intoxication by an overdose, or insufficient action by loss 
of part of the drug on its route to the circulation. No inconve- 
nience in their application is experienced, no uncleanliness likely 
to call the attention of others to the ailment connected with it, 
and gastro-intestinal irritation and skin lesions are practically 
unknown. 

Simultaneously with the administration of mercury a tonic Tonics 
must be given. I have found peptomanganate of iron and the 
irontropon most valuable. 

Irrespective of the way mercury is incorporated, symptoms Mercurialism 
of mercurialism are occasionally observed; sometimes due to an 
overdose and at others to an individual idiosyncrasy. The mani- 
festations observed are stomatitis, gastro-intestinal irritation, 
toxic erythema, anemia, neurosis, and neuritis. As soon as these 
symptoms occur, the administration of mercury must be dis- 
continued. Most of the trouble soon passes off and the treat- 
ment may be resumed. In the cases of idiosyncrasy other reme- 
dies will have to be employed. 

Iodin is next to mercury and most used in combating syph- iodine prepara- 
ilis, especially the potassium iodid, the sodium iodide and the tions 
rubidiumiodide. The latter is comparatively free from the toxic 
qualities of the other two preparations. The dose varies from 
1.0 to 10.0 and more pro die. It is given by mouth in liquid or 



, 



602 SYPHILIS 

pills, excepting in intolerance of the stomach, when it is used 
in aqueous solution by rectum. 



Or 
Or 

Or 
Or 



3 

Potass, iodid, 

Sodium iodid, 



Eubid. iodid, 5.0-10.0 

Aqua distill., 200.0 

Sig. One to three tablespoonfuls in water, 

essence of pepsin, or milk, three times daily. 

Potass, iodid, 10.0 

Sodium icd. 

Sacchar. lact., 5.0 

M. Ft. Pill No. 50. 

Sig. Two to ten pills a day. 

lodism The most common symptoms of iodin intoxication (iodism) 

are severe headache, coryza, edema around the eyes, cough, acne 
and iodin exanthema. Should any of these symptoms appear 
the iodin medication must be discontinued. The addition of a 
grain of belladonna extract to fifty pills frequently prevents 
iodism. 

Potassium iodid is incompatible with calomel, forming a 
caustic compound and they should not be prescribed together. 

The iodid preparations are very effectual in the late forms 
of syphilis — serpiginous syphilide of the skin, gummata of the 
skin, fascia, muscles and bone syphilis, ulcerations of the 
pharynx and larynx, syphilis of internal organs and the cen- 
tral nervous system. They have to be used in malignant syphilis, 
instead of mercury, at least for a while preceding the adminis- 
tration of the latter drug and in all cases of idiosyncrasy for 
mercury. It is very effective with or without antipyrin for se- 
vere headache, pain in bones and joints preceding or accompany- 
ing the eruptive stage. 

Antipyrin, 2.0—3.0 

Potassium iodid, 4.0 — 8.0 

Aqua distill., 200.0 

Sig. A tablespoonful in water, twit > or three 
times a day. 



SYPHILIS 603 

It is the remedy of choice in syphilis of tuberculous, scrofu- ^^. d treat " 
lous, highly emaciated patients. In malignant syphilis, iodin 
preparations instead of mercury are used until the general con- 
dition of the patient permits the employment of the latter 
drug. The indications for the choice of iodine in these cases are 
easily recognized by the fact that in spite of the mercury the 
progressive nature of the lesions cannot be checked. In some very 
stubborn cases decided improvement will follow the combined 
administration of iodine and mercury after either of them em- 
ployed separately have failed to be effectual. 

How long to continue the treatment of syphilis depends on Duration of 
the views one holds regarding the nature of the trouble. Some 
believe in the temporary treatment, others in the continuous 
treatment, and the followers of Fournier in the chronic inter- 
mittent or interrupted treatment. While the adherents of the 
first method believe in treating only in the presence of visible 
lesions, the advocates of the second method administer mercury, 
or mercury alternating with iodine and other drugs, more or 
less continuously for a number of years, irrespective of the pres- 
ence or absence of luetic manifestations. The temporary treat- 
ment evidently is inadequate, while under the continuous method 
a tolerance for the specific drugs is established which weakens 
their therapeutic effect. 

The best results observed belong to the third method. The 
treatment should extend over a term of not less than three 
years, and in the absence of special indications not over five 
years. If injections or inunctions are used, the patient should 
first receive as many as are required to make the symptoms dis- 
appear, and then half as many more. Then comes an interval 
of about two months which, in the first year, may be utilized 
to give iodine for four weeks. Then again half as many injec- 
tions or inunctions as were given altogether in the first course, 
and this followed by four weeks of iodine medication and four 
weeks of rest. The same procedure is repeated once more. In 
the second and third year, unless the indications require a change 
from the routine, this course of treatment may be given twice 
each year, and in the fourth and fifth year one course only. 

Hereditary syphilis has to be treated upon the same prin- Hereditary 
ciples as the acquired form. As a result of the preventative 
mercurial treatment of a luetic mother apparently healthy chil- 
dren are frequently born. The same procedure ought to be 
tried where the mother appears healthy but the father is luetic 



INDEX 



Abortion of Malarial Attack, 547. 
Abscess of Lung, 303-306. 

of Prostate, 253. 
Acetanilid in Malaria, 548. 

in Muscular Rheumatism, 164. 

in Tuberculosis, 326. 
Achylia Gastrica, 398-401. 
Acidosis, 22,7. 

in Diabetes, 131. 
Aconite in Capillar)' Bronchitis, 293. 

in Endocarditis, 50. 

in Epistaxis, 274. 

in Grave's Disease, 107. 

in Hemoptysis, 309. 

in Palpitation, 69. 

in Pneumonia, 522. 

in Tonsillitis, 263. 
Acute Gastritis, 343. 

Laryngitis, 276-279. 

Peritonitis, circumscribed, 471-481. 
Acupuncture in Aneurism, 60. 

in Malaria Spleen, 549. 

in Muscular Rheumatism, 165. 
Addison's Disease, no-ill. 
Adenitis, tuberculous, 90. 
Adhesions in Appendicitis, 480. 

in Cholelithiasis, 502. 
Adonis Vernalis in heart disease, 33. 
Adrenal Extract in Addison's Disease, no-ill. 

Glands in Addison's Disease, no. 
Adrenalin in Acute Peritonitis, 471. 

in Gastric Ulcer, 376. 

in Hay Fever, 270. 

in Intestinal Hemorrhage, 440. 

in Rhinitis, 269. 

in Scurvy, 96. 
Agaricin in Night Sweats, 327. 
Air Inflation in Ileus, 429, 430. 
Albuminuria, drugs to reduce, 201. 
Alcohol as an Antipyretic, 509. 

as cause of Arterio-sclerosis, 53. 

Caloric value of, 138. 

Dressing in Rheumatic Fever, 552. 

for Mouth wash, 261. 

in Achylia Gastrica, 400. 

in Acute Gastritis, 353. 

in Acute Peritonitis, 471. 

in Bright's Disease, 214. 

in Cholelithiasis, 498. 

in Compensated Heart Lesions, 20. 

in Gout, 188. 

in Hyperchlorhydria, 396. 

in Hyposecretion, 400. 

in Influenza, 561. 

in Nervous Diarrhea, 460. 



in Nervous Dyspepsia, 418. 

in Night Sweats, 326, 327. 

in Obesity, 156. 

in Pertussis, 564. 

in Smallpox, 583. 

in Tuberculosis, 320, 325. 

in Typhoid Fever, 534. 

in Urethritis, 249. 

in Uric Acid Diathesis, 182. 

with Digitalis, 31. 
Alcoholism and Pneumonia, 527. 
Alimentary Constipation, 444. 
Aleuronat Bread, 126. 
Alimentary Glycosuria, 146. 
Alkalies in Acute Nephritis, 202. 

in Arterio-sclerosis, 55. 

in Bronchitis, 280. 

in Chronic Gastritis, 356, 361-362. 

in Coma, 145. 

in Diabetes, 136, 138. 

in Endocarditis, 50. 

in Gout, 188. 

in Hepatic Cirrhosis, 496. 

in Hyperchlorhydria, 397. 

in Muscular Rheumatism, 164. 

in Myocarditis, 48. 

in Nephrolithiasis, 227. 

in Pericarditis, 52. 

in Rheumatic Fever, 552. 

in Uremia, 238. 
Alkaline-Quinine Treatment, 169. 
Alkaline-Saline Waters in Intestinal Catarrh, 
421. 

Wash in Rhinitis, 268. 

Waters, 40. 

Waters in Bronchitis, 284. 

Waters in Chronic Gastritis, 358. 

Waters in Hyperchlorhydria, 394, 398. 

Waters in Icterus, 486. 
Alloxuric Bases, see Purin Bases. 
Almond Bread, 127. 
Aloes in Cardiac Dropsy, 44. 

in Constipation, 454. 

in Hepatic Congestion, 40. 
Aloin for hypodermic purgation, 45^, 
Artificial Respiration, 304. 
Altitude in Anemia, 79. 

in Arterio-sclerosis, 54. 

in Bronchitis, 284. 

in Chronic Nephritis, 221. 

in Emphysema, 297. 

in Grave's Disease, 105. 

in Tuberculosis, 316-318. 
Alum Wash in Night Sweats, 326. 
Ambrosia, cause of Hay Fever, 269. 
Amebic Dysentery, 558. 
Ammonia in Asthma, 290. 



6o6 



in Heart Disease, 32. 

in Palpitation, 69. 

aromatic spirits of, in Heart Disease, 32. 
Ammonium Carbonate in Epistaxis, 277. 

Chloride in Bronchitis, 284, 289. ., 

Chloride in Pulmonary Hyperemia, 38. 
Amyl Nitrite in Angina Pectoris, 64. 

in Arterio-sclerosis, 56. 

in Palpitation, 69. 
Amylolytic Ferments, 366. 
Anacidity, see Achylia. 
Anal leeching, 40. 

in Epistaxis, 276. 
Analeptics, 32. 

in Anemia, 78. 

in Acute Peritonitis, 471. 

in Capillary Bronchitis, 294. 

in Cholelithiasis, 504. 

in Diphtheria, 543. 

in Emphysema, 299. 

in Epistaxis, 273, 274. 

in Hemoptysis 310. 

in Intestinal Catarrh, 418. 

in Palpitation, 69. 

in Pulmonary Edema, 302. 

in Pulmonary Infarct, 304. 
Analgesics in Cholelithiasis, 503. 
Anchylostoma, 467. 
Anemia, 71-86. 

after hemorrhage, 78. 

cerebral, 35. 
Anemia, Classification, 71. 
Anemia, progressive, pernicious, 71. 

simple, 76-80. 
Aneurism of Aorta, 56-62. 
Angina Pectoris, 62-65. 
Angio-neurotic Edema, 299. 
Anise in Chronic Gastritis, 363. 
Anise Seed as a Carminative, 463. 
Anodynes in Gout, 186. 

in Muscular Rheumatism, 164. 
Anodyne Ointments, 334. 
Anorexia in Simple Anemia, 78. 

in Tuberculosis, 329. 
Antacids in Gastric Ulcer, 372. 
Antiluetic Treatment in Endocarditis, 50. 
Antineuralgics in Aneurism, 61. 

in Gastralgia, 412. 

in Gout, 188. 

in Influenza, 560. 

in Muscular Rheumatism, 164. 
Antineuralgic Remedies, 144. 
Antipyretics in Diphtheria, 542. 

in Infectious Diseases, 508, 509. 

in Measles, 572. 

in Pneumonia, 523. 

in Tuberculosis, 326. 

in Typhoid Fever, 531, 532. 
Antipyrin in Cholelithiasis, 503. 

in Cystitis, 246. 

in Diabetes Insipidus, 195. 

in Fevers, 509. 

in Gastralgia, 412. 

in Gout, 188. 

in Hepatic Cirrhosis, 496. 



in Malaria, 548. 

in Pertussis, 565. 

in Pleurisy, 332. 

in Rheumatic Fever, 552. 
., in Syphilis, 602. 

in Tetanus, 557. 

in Tuberculosis, 326. 
Antisclerosin in Arterio-sclerosis, 56. 
Antiseptics in Chronic Gastritis, 356. 

Intestinal, in Typhoid Fever, 531. 
Antiseptic Treatment of Infectious Diseases, 

507. 
Antispasmodics in Angina Pectoris, 63. 
Antistreptococcic Serum in Scarlatina, 568. 
Antitoxic Unit, 555. 
Antitoxin, of Tetanus, 554, 555. 

of Diphtheria, 539-541. 
Anuria, 237. 

in Acute Nephritis, 201. 

in Yellow Fever, 589. 
Aortic Aneurism, 56-62. 

Insufficiency, 17. 

Stenosis, 17. 
Aortitis, Chronic, 53-56. 
Aperients, see Laxatives. 
Aphthous Stomatitis, 261. 
Apocodeine for Hypodermic Purgation, 456. 
Apomorphine in Acute Gastritis, 343. 

in Bronchitis, 282, 284. 

in Heart Disease, 38. 
Appendicitis, 471-481. 
Argyrol in Cystitis, 246. 
Aromatic Sulphates, 207. 
Arrhythmia, 70. 
Arterio-sclerosis, 53-56. 
Arsenic in Asthma, 288. 

in Chlorosis, 85. 

in Diabetes, 137. 

in Grave's Disease, 107. 

in Leukemia, 87, 88, 91. 

in Malaria, 548. 

in Myocarditis, 49. 

in Nervous Diarrhea, 460. 

in Osteomalacia, 194. 

in Pernicious Anemia, J2. 

in Simple Anemia, 79, 80. 

in Thyroidism, 103. 

in Tuberculosis, 324. 
Arsenic Waters in Anemia, 80. 
Arthritis Deformans, 162, 166-172. 

in Pneumonia, 530. 

in Obesity, 150. 
Arthritism, 161. 
Articular Rheumatism, Acute, 161. 150, 554. 

in Myocarditis, 48. 
Asafetida as a Carminative, 463. 

in Diabetes Insipidus, 195. 

in Palpitation, 69. 
Asiatic Pill in Pernicious Anemia, 73. 
Ascaris Lumbricoides, see Round Worm. 
Aspidium for Tape Worm, 465. 
Aspiration of Stomach Contents, 345. 
Aspirin in Rhinitis, 268. 

in Diabetes, 134. 

in Laryngitis, 276. 



607 



in Gout, 188. 

in Influenza, 561. 

in Pleurisy, 332. 

in Rheumatic Fever, 551. 

in Chronic Rheumatism, 169. 
Asthma, bronchial, 286, 290. 

Cigarettes, 289. 

in Emphysema, 296. 

Points, 287. 

uremic, 241. 
Astringents in Dysentery, 559. 

in Intestinal Catarrh, 417. 

in Intestinal Ulcer, 439. 

in Urethritis, 251. 
Atheroma, danger of digitalis in, 30. 
Athyreosis Chronica, 101. 
Atonic Constipation, 446. 

Atony of the Stomach, see Motor Insufficiency. 
Atrophic Cirrhosis of the Liver, 488-497. 
Atropine as an antidote to digitalis, 29. 

in Asthma, 288. 

in Bronchitis, 280, 284, 285. 

in Cholelithiasis, 503. 

for thirst in Diabetes, 132. 

in Gastric Ulcer, 372. 

in Hay Fever, 270. 

in Hyperchlorhydria, 397. 

in Ileus, 432. 

in Mercurial Stomatitis, 263. 

in Night Sweats, 327. 

in Osteomalacia, 194. 

in Pulmonary Edema, 301. 

in Rhinitis, 268. 

in Uremic Dropsy, 240. 
Autotoxemia in Anemia, 72, 76. 
Axial Rotation of the Bowel, 425. 

B 

Balsams in Bronchitis, 282, 284. 

in Cystitis, 244. 

in Tuberculosis, 328. 
Bandaging in Floating Kidney, 235. 

in Motor Insufficiency, 389. 

in Mucous Colitis, 443. 

in Tuberculous Peritonitis, 482. 
Banti's Disease, 90. 
Banting Cure for Obesity, 152. 
Bathing in Anemia, 79. 

in Arterio-sclerosis, 54. 

in Bright's Disease, 217, 218. 

in Capillary Bronchitis, 291. 

in Cardiac Dropsy, 42. 

in Diphtheria, 543. 

in Heart Disease, 25. 

in Icterus, 488. 

in Mucous Colitis, 442. 

in Neurasthenia, 404, 405. 

in Palpitation, 67. 

in Pharyngitis, 267. 

in Pleurisy, 333. 

in Muscular Rheumatism, 164. 

in Rhinitis, 267. 

in Tetanus, 556. 

in Uremia, 238. 

in Uric Acid Diathesis, 183, 184. 



in Smallpox, 585. 
Baths, Carbonated, 25. 

Medicated, 25. 

Salt, 25. 
Basedow's Disease, 104-109. 
Bed Sores, see Decubitus, 539. 
Belching, Nervous, 408. 
Belladonna in Acute Gastritis, 347. 

in Asthma, 289, 290. 

in Bronchitis, 2S0. 

in Cholelithiasis, 503. 

in Cystitis, 244. 

in Gastric Ulcer, 372. 

in Hay Fever, 270. 

in Hyperchlorhydria, 397. 

in Pertussis, 564. 

in Renal Colic, 232. 

in Rhinitis, 268. 

in Spastic Constipation, 446. 
Benzo-naphthol in Intestinal Catarrh, 416. 

as Mouth Wash, 261. 
Benzoic Acid in Cystitis, 244. 

in Nephrolithiasis, 231. 
Benzoin in Bronchitis, 282, 284. 

in Pulmonary Hyperemia, 38. 
Beta-naphthol in Intestinal Catarrh, 416. 

in Rheumatism, 169. 
Bier's Method in Chronic Rheumatism, 171. 
Bigeminal Pulse, 70. 
Bile in Icterus, 488. 

Acids in Bright's disease, 207. 

Acids in Cholelithiasis, 500. 

Acids in Icterus, 487, 488. 

Acids in Uremia, 238. 
Biliary Cirrhosis of the Liver, 488, 497. 
Bismuth Carbonate in Gastric Ulcer, 2>7Z- 

Cresolate in Intestinal Catarrh, 421. 

in Diarrhea, 459. 

in Hematemesis, 376. 

Phenolate in Intestinal Catarrh, 421. 

Salts in Intestinal Hemorrhage, 440. 

Salts in Intestinal Ulcer, 438, 439. 

Subnitrate in Bright's Disease, 207. 

Subnitrate in Flatulency, 463. 

Subnitrate in Gastric Ulcer, 373. 

Subnitrate in Intestinal Catarrh, 420. 

Subsalicylate in Intestinal Catarrh, 420. 

Sulphocarbolate in Intestinal Catarrh, 
421. 
Bitter Almonds in Chronic Gastritis, 363. 
Bitters in Chronic Gastritis, 362. 

in Tuberculosis, 330, 331. 
Black Vomit in Yellow Fever, 588. 
Blaud's Pill in Chlorosis, 84. 
Bleeding, see Venesection. 
Blisters in Gout, 187. 
Bloodletting, see Venesection. 
Bone Marrow in Leukemia, 88. 
Bone Marrow in Pernicious Anemia, 74. 
Boric Acid in Hyperchlorhydria, 397. 

in Cystitis, 244. 
Bothriocephalus latus, see Tape Worm. 
Bougies in Urethritis, 252, 256. 
Boundary of tolerance in Diabetes, 121. 
Bowel Irrigation, 414. 



6o8 



INDEX 



Bradycardia, 70. 

Brain Ischemia in Aortic Insufficiency, 18. 

passive hyperemia of, 34-38. 
Brand Treatment in Typhoid Fever, 535. 
Brandy in Heart Disease, 32. 
Brayera for Tape Worm, 465. 
Bright's Disease, 204-222. 
Broken Compensation, 26-34. 
Bromelin in Chronic Gastritis, 365. 
Bromides in Aortic Insufficiency, 19. 

in Asthma, 289. 

in Diabetes, 134. 

in Diabetes Insipidus, 195. 

in Grave's Disease, 107. 

in Insomnia, 35. 

in Palpitation, 68. 

in Pulmonary Edema, 300. 

mode of action, 35. 
Bromoform in Gastralgia, 412. 

in Pertussis, 565. 
Bronchiectasis, see Bronchitis, Chronic. 
Bronchiolitis Capillaris, 290. 
Bronchitis, acute, 279-287. 

Capillary, 290-294. 

Chronic, 283-286. 

in Obesity, 148. 

Profunda, 290. 

Tent, 280. 
Broncho-pneumonia, 290-294. 
Buchu in Cystitis, 244. 



Cachexia thyreopriva, 101. 

strumipriva, 101. 
Cacodylate of Soda, see Sodium Cacodylate. 
Caffein Citrate in Heart Disease, 34. 

in Acute Nephritis, 202. 

in Heart Disease, 32. 

in Pertussis, 565. 

in Pleurisy, 336. 
Calcium Carbonate in Hyperchlorhydria, 398. 

in Nephrolithiasis Urica, 228, 229. 

in Osteomalacia, 193. 

in Uremia, 238. 
Calcium Chloride in Hemophilia, 98. 

in Internal Hemorrhage, 440. 

in Tuberculosis, 325. 

Lacto-phosphate in Rachitis, 192. 

Phosphate in Osteomalacia, 193. 

reduction in Arterio-sclerosis, 54. 
Calomel as a diuretic, 43. 

in Acute Gastritis, 344. 

in Acute Nephritis, 202, 204. 

in Cystitis, 243. 

in Dysentery, 558. 

in Gout, 187. 

in Hepatic Congestion, 40. 

in Icterus, 485. 

in Influenza, 560. 

in Intestinal Catarrh, 414, 416. 

in Laryngitis, 276. 

in Tonsillitis, 263. 

in Typhoid Fever, 531. 
Caloric Requirement, 113. 

Values, 113-117. 



Calorie, Definition of, 113. 
Calorimetric Methods, 113-118. 
Camphoric Acid in Cystitis, 244. 
Camphor in Hay Fever, 270. 
Camphor in Heart Disease, z 2 - 

in Hemoptysis, 310. 

in Palpitation, 69. 

in Rhinitis, 268. 
Cancrum Oris, 261, 262. 
Cannabis Indica in Asthma, 290. 

in Tetanus, 557. 
Cantharidal Plaster, 334. 
Capillary Bronchitis, 290-294. 
Capsicum in Hay Fever, 270. 
Caraway in Chronic Gastritis, 363. 

Seed as a Carminative, 463. 
Carbo Animalis, 463. 

Ligni, 463. 
Carbohydrates, caloric value of, 113. 
Carbolic Acid in Bronchitis, 284. 

in Hay Fever, 270. 

in Malaria, 548. 

in Pertussis, 565. 

in Septic Endocarditis, 50. 

in Tetanus, 555. 
Carbonated Baths, 25. 

Waters in Chronic Gastritis, 358. 
Carbonic Acid Baths in Bright's Disease, 217* 
Carbuncle in Obesity, 149. 
Carcinoma of the Stomach, 378-384. 
Cardamoms as a Carminative, 463. 

in Chronic Gastritis, 363. 
Cardiac Asthma, 286. 

Cirrhosis of the Liver, 488-497. 

Dropsy, 42-47. 

Edema, 42-47. 

Failure, 528. 

Gout, 185. 

Stasis, 34-42. 
Cardio-renal Disease, 197, 204. 

-Spasm, 407. 
Caries, dental, in Diabetes, 140. 
Carlsbad in Diabetes, 136. 

in Intestinal Catarrh, 421, 

in Obesity, 158. 

Salts in Gastric Ulcer, 371. 
Carminatives in Flatulency, 462, 463. 
Carniferrin in Chlorosis, 85. 
Cascara in Acute Nephritis, 204. 

in Constipation, 453. 

in Hepatic Congestion, 40. 
Castor Oil Enema in Constipation, 450. 

in Acute Gastritis, 346. 

in Acute Nephritis, 204. 

in Cardiac Dropsy, 44. 

in Icterus, 485. 

in Intestinal Catarrh, 414, 421. 
Catarrh, Acute Intestinal, 413-418. 

Chronic Intestinal, 418-423. 

of Bowels in Diabetes, 142. 

of Stomach in Diabetes, 142. 
Catarrhal Jaundice, 485-488. 

Stomatitis, 261. 
Catharsis in Acute Nephritis, 204. 

in Cardiac Dropsy, 44. 



609 



in Hepatic Cirrhosis, 495 

in Palpitation, 69. 

in Pericarditis, 52. 

in Pleurisy, 335. 

in Pulmonary Edema, 300. 

in Pyelitis, 223. 
Cathartinic Acid for hypodermic purgation, 

456. 
Cathartics, see Laxatives. 
Catheterization in Prostatitis, 253. 
Catechu in Intestinal Catarrh, 420. 

in Pyelitis, 223. 

in Scurvy, 96. 
Cauterization in Epistaxis, 273. 
, Cauterization of Syphilitic Chancre, 594. 

in Urethritis, 257. 
Cerebral Gout, 185. 
Cerium Oxalate in Vomiting, 239. 
Chalk in Gastric Ulcer, 374. 
Champagne in Heart Disease, 32. 
Chancre in Syphilis, 594-596. 
Charcoal in Flatulency, 463. 
Chenopodium for Round Worm, 466. 
Cheyne-Stokes breathing, 34. 
Chill, ; n Infectious Diseases, 508. 
Chloral, Contraindications to, 34. 

dangers of in Heart Disease, 34. 

in Asthma, 289. 

in Cholelithiasis, 503. 

in Delirium Tremens, 527. 

in Diabetes, 134. 

in Epistaxis, 275. 

in Insomnia, 34. 

in Palpitation, 69. 

in Renal Colic, 232. 

in Tetanus, 557. 

in Uremic Attack, 242. 
Chloralamid in Asthma, 289. 

in Insomnia, 36. 
Chloralose in Insomnia, 36. 
Chloretone in Insomnia, 36. 
Chlorides in Tuberculosis, 325. 
Chloride Restriction in Bright's Disease, 215. 
Chloroform in Aneurism, 62. 

in Angina Pectoris, 64. 

in Asthma, 289. 

in Cholelithiasis, 503. 

in Gastralgia, 412. 

in Palpitation, 69. 

in Pleurisy, 334. 

in Renal Colic, 232 

in Rhinitis, 268. 

in Tetanus, 557. 

in Uremic Asthma, 241. 

in Uremic Attack, 242. 

in Vomiting, 240. 
Chloroform Water in Gastric Ulcer, ^73- 
Chlorosis, 81-86. 
Chinosol in Cystitis, 247. 
Cholagogues in Cholelithiasis, 499. 

in Hepatic Cirrhosis, 496. 

in Icterus, 487. 
Cholangitis, 497-504. 
Cholecystitis, 497-504. 
Cholelithiasis, 497-504. 



Acute Attack, 502. 5m 
Cholemia, 491. 
Christian Science, 287. 
Chronic Constipation, 444-456. 

Gastritis, 355-366. 

Intestinal Catarrh, 418-423. 

Peritonitis, 481-484. 

Rheumatism, 162. 
Cinchona in Chronic Gastritis, 363. 
Cinnamic Acid in Tuberculosis, 324. 
Cinnamon as a Carminative, 463. 

in Chronic Gastritis, 363. 
Cirrhosis of the Liver, 488-497. 

of the Liver in Obesity, 149. 
Climate in Anemia, 79. 

in Arterio-sclerosis, 54. 

in Asthma, 288. 

in Bronchitis, 283. 

in Chronic Nephritis, 221. 

in Emphysema, 296. 

in Grave's Disease, 105. 

in Hay Fever, 270. 

in Heart Disease, 24. 

in Pertussis, 563. 

in Tuberculosis, 316-318. 
Clothing in Acute Nephritis, 200. 

in Anemia, 79. 

in Cholelithiasis, 499. 

in Chronic Rheumatism, 166. 

in Floating Kidney, 236. 

in Intestinal Catarrh, 423. 

in Muscular Rheumatism, 163. 

in Palpitation, 57. 

in Pharyngitis, 267. 

in Rheumatic Fever, 553. 

in Rhinitis, 267. 

in Tuberculosis, 316. 
Cloves as Carminatives, 463. 
Cocaine, Administration Internally, 19. 

as Mouth Wash, 261. 

in Acute Gastritis, 347. 

in Aneurism, 61. 

in Asthma, 289. 

in Cystitis, 246. 

in Dysentery, 559. 

in Gastralgia, 19, 412. 

in Hay Fever, 270. 

in Rhinitis, 267. 

in Vomiting, 240. 
Codeine in Bronchitis, 280. 

in Insomnia, 36. 

in Muscular Rheumatism, 164. 

in Pulmonary Hyperemia, 38. 

in Smallpox, 580. 

in Tuberculosis, 328. 
Codliver Oil in Pertussis, 564. 

in Osteomalacia, 193. 

in Rachitis, 192. 

in Tuberculosis, 325. 
Coffee in Compensated Heart Lesions, 20. 

in Heart Disease, 32. 

in Hemoptysis, 310. 

in Chronic Nephritis, 214. 

in Palpitation, 69. 
Colchicum in Gout, 187-188. 



6io 



in Rheumatic Fever, 552. 
Cold in Pericarditis, 51. 

in Pseudo-leukemia, 93. 
Colica Mucosa, 441-443. 
Collapse in Acute Peritonitis, 470. 

in Diphtheria, 543. 
Colocynth in Cardiac Dropsy, 44. 

in Gout, 187. 
Colombo in Intestinal Catarrh, 420. 
Colonic Flushing in Icterus, 485. 

in Intestinal Catarrh, 422. 

Irrigation in Flatulency, 464. 
Coma, Diabetic, 144, 145. 

Communal Protection in Pneumonia, 514, 515. 
Compensated Valvular Lesions, 17-26. 
Compress, see Priessnitz Compress. 
Compresses in Laryngitis, 2^. 

in Aneurism, 60. 
Condurango in Chronic Gastritis, 363. 
Congenital Heart Lesions, 17. 
Constipation, Chronic, 444-456. 

in Appendicitis, 477. 

in Chlorosis, 82. 

in Diabetes, 143. 

in Obesity, 149. 
Convallaria in Heart Disease, 33. 
Copaiba in Bronchitis, 282, 284. 

in Pyelitis, 223. 
Copper Salts in Tuberculosis, 324. 

Sulphate in Urethritis, 251. 
Corrosive Sublimate for Thread Worms, 467. 
Coryza Vasomotoria, 269-271. 
Cotarnine in Epistaxis, 274. 

in Hemoptysis, 311. 
Cough Drops, 283. 

in Pneumonia, 524. 

in Tuberculosis, 327-329. 

Syrups, 283. 
Counter-irritation in Appendicitis, 478. 
Cradin in Chronic Gastritis, 365. 
Cravings in Chlorosis, 82. 
Creosotal in Tuberculosis, 323. 
Creosote in Diabetes, 137. 

in Intestinal Catarrh, 416. 

in Pertussis, 565. 

in Tuberculosis, 322, 323. 
Cresolene in Pertussis, 565. 
Cretinism, 101-104. 
Croton Oil in Cardiac Dropsy, 44. 
Croup, 543- . 

Crystallose in Diabetes, 138. 
Cubebs in Bronchitis, 282, 284. 
Cupping in Acute Nephritis, 200. 

in Bronchitis, 29. 

in Dropsy, 46. 

in Pulmonary Edema, 300. 

in Pleurisy, 333. 

in Pneumonia, 524. 

Technique of, 39. 
Cusso for Tape Worm, 465, 466. 
Cutaneous Gout, 185. 
Cystitis, 242-248. 
Cystoscopy, 247-248. 



Decapsulation of the Kidneys, 222. 
Decompensated Valve Lesion, 20-34. 
Decubitus in Typhoid Fever, 539. 
Delayed Resolution in Pneumonia, 529. 
Delirium Cordis, 70. 

in Pneumonia, 527. 

Tremens, 527. 
Dermatol in Intestinal Catarrh, 421. 
Dermol in Intestinal Catarrh, 421. 
Disinfectants in Intestinal Ulcer, 439. 
Disinfection in Smallpox, 575. 
Dextrose in Hyperchlorhydria, 395. 
Diabetes and Uric Acid Diathesis, 185. 

Drugs in, 132-139. 

Insipidus, 194-196. 

in Organic Nervous Diseases, 146. 

in Medium Severity, 128-130. 

Mellitus, 1 18-147. 

Mild Type, 124, 125, 128. 

Neurotic, 146. 

Phosphaticus, 234. 

Severe Type, 131, 132. 

Syphilitic, 147. 
Diabetic Breads, 126, 127. 

Coma, 144, 145. 

Gangrene, 145. 

Test Meal, 121, 122. 
Diaphoresis in Hepatic Cirrhosis, 495. 

in Pulmonary Edema, 300. 

in Pleurisy, 332. 
Diarrhea, 456-461. 

Dyspeptica, 457. 

Gastrica, 456. 

Malarial, 413. 

Nervosa, 459-461. 

Uremic, 240, 413. 
Diastase in Chronic Gastritis, 366. 
Diet. 

n Achylia Gastrica, 399. 

n Acute Gastritis, 347. 

n Acute Intestinal Catarrh, 415, 416. 

n Acute Nephritis, 198-200. 

n Alimentary Constipation, 444, 445. 

n Angina Pectoris, 62. 

n Aneurism, 57. 

n Appendicitis, 475-476, 479. 

n Arterio-sclerosis, 54. 

n Asthma, 287. 

n Atonic Constipation, 446, 447. 

n Bright's Disease, 208-214. 

n Chlorosis, 82. 

n Cholelithiasis, 498, 505. 
Chronic Gastritis, 359. 

n Chronic Intestinal Catarrh, 418-420. 

n Chronic Nephritis, 208-214. 

n Chronic Rheumatism, 166, 167. 

n Chronic Stenosis of the Bowel, 437. 

n Chronic Uremia, 238. 

n Coma, 144. 

n Compensated Heart Lesions, 20-21. 

n Cystitis, 243. 



6n 



in Diabetes of mild type, 125-128. 

in Diabetes of Medium Severity, 128-130. 

in Diabetes of severe type, 131-132. 

in Diarrhea, 458. 

in Diphtheria, 543. 

in Dysentery, 558. 

in Emphysema, 298. 

in Endocarditis, 51. 

in Failing Compensation, 27. 

in Fevers, 509-511. 

in Flatulency, 462. 

in Gastric Carcinoma, 379, 380. 

in Gastric Ulcer, 367, 370, 371. 

in Gout, 177, 183, 188. 

in Grave's Disease, 105, 106. 

in Hemophilia, 97. 

in Hemoptysis, 312. 

in Hepatic Cirrhosis, 493-495. 

in Hepatic Insufficiency, 493-495. 

in Hyperchlorhydria, 394-396. 

in Hyposecretion, 399. 

in Icterus, 485-486. 

in Ileus, 436. 

in Intestinal Ulcer, 438. 

in Leukemia, 89. 

in Measles, 573. 

in Membranous Enteritis, 443. 

in Motor Insufficiency, 386, 387. 

in Mucous Colitis, 443. 

in Muscular Rheumatism, 165. 

in Nervous Diarrhea, 460. 

in Nervous Dyspepsia, 412. 

in Nephrolithiasis Oxalurica, 233. 

in Nephrolithiasis Phosphatlca, 234. 

in Nephrolithiasis Urica, 227. 

in Obesity, 150-158. 

in Osteomalacia, 194. 

in Palpitation, 68. 

in Passive Hepatic Congestion, 40. 

in Pericarditis, 51, 52. 

in Pernicious Anemia, 72. 

in Pertussis, 563, 567. 

in Purpura, 99. 

in Pyelitis, 223. 

in Pyonephrosis, 223. 

in Rachitis, 190-191. 

in Rheumatic Fever, 553. 

in Scarlatina, 569. 

in Scurvy, 95, 96. 

in Simple Anemia, JJ, 78. 

in Smallpox, 581, 583. 

in Tetanus, 557. 

in Tuberculous Peritonitis, 481. 

in Tuberculosis, 313, 319, 321, 329, 330. 

in Typhoid Fever, 532-534. 

in Uric Acid Diathesis, 177-183. 

in Yellow Fever, 590. 
Digestibility of Foods, 347-354- 
Digestive Ferments in Chronic Gastritis, 
364. 

in Chronic Carcinoma, 381. 
Digital Compression in Epistaxis, 273. 
Digitalein in Heart Disease, 31. 
Digitalin in Gastric Hyperemia, 41. 

in Heart Disease, 31. 



Digitalis, Cumulative Action, 28. 

Continued Use of, 29. 

Contraindications, 29. 

in Aortic Disease, 29. 

in Arterio-sclerosis, 56. 

in Atheroma, 30. 

in Acute Nephritis 202. 

in Acute Peritonitis, 471. 

in Delirium, 527. 

in Diagnosis of Myocarditis, 30. 

in Endocarditis, 50. 

in Gastric Hyperemia, 41. 

in Grave's Disease, 107. 

in Heart Disease, 28-30. 

in Palpitation, 69. 

in Pericarditis, 52. 

in Pleurisy, 336. 

in Pneumonia, 525. 

Intoxication, 28. 

Preparations of, 30. 

"Pure Principles" of, 29, 31. 

Tolerance and Susceptibility, 28. 

With Alcohol, 31. 
Digitophyllin in Heart Disease, 31. 
Digitoxin in Heart Disease, 31. 
Dilatation of the Stomach, see Motor Insuffi- 
ciency. 
Dionin in Bronchitis, 280. 

in Tuberculosis, 328. 
Diphtheria, 539-544- 

Antitoxin, 539-54*. 
in Urethritis, 255. 
Diphtheritic Urethritis, 255. 
Diuretics in Pericarditis, 52. 

in Pleurisy, 335. 

in Pulmonary Edema, 300. 

in Tuberculous Peritonitis, 482. 

in Uremia, 237, 241. 

in Yellow Fever, 589. 
Diuretin as a Diuretic, 43. 

in Heart Disease, 32. 

in Pleurisy, 336. 
Diseases of Metabolism, 1 13-196. 
Distoma Hematobium as Cause of Anemia, 

72. 
Dizziness in Aortic Insufficiency, 18. 
Douches in Chronic Rheumatism, 171. 

Vaginal, in Urethritis, 252. 
Douching of Stomach in Achylia Gastrica, 
400. 

in Constipation. 449. 

in Gastralgia, 412. 

Hyperchlorhydria, 396. 

in Hyposecretion, 400. 

in Motor Insufficiency, 389. 
Dover's Powders in Bronchitis, 279. 

in Capillary Bronchitis, 294. 

in Influenza, 560. 

in Laryngitis, 276. 

in Pleurisy, 332. 

in Rhinitis, 268. 
Drastics, see Laxatives. 
Dressings in Chronic Rheumatism, 167. 
Drink Restriction in Acute Nephritis, 198. 

in Aneurism, 58. 



6l2 



in Arterio-sclerosis, 54. 

in Compensated Heart Lesions, 2: 

in Diabetes Insipidus, 195. 

in Motor Insufficiency, 387. 

in Obesity, 155. 
Drink Restriction in Pleurisy, 336. 
Dropsy, Cardiac, 42-47. 
Drugs in Bright's Disease, 215, 216. 
Dulcin in Diabetes, 138. 
Dunbar's Serum in Hay Fever, 271. 
Dysentery, 558-560. 
Dyspepsia in Diabetes, 141. 

Nervous, 412. 
Dyspnea in Obesity, 148. 



Ecstasy of the Stomach, see Motor Insuffi- 
ciency. 
Eczema in Obesity, 149. 
Edema, Cardiac, 42-47. 

in Uremia, 240. 

of the Glottis, 240. 

Pulmonary, 299-303. 
Effervescent Salts in Constipation, 455. 
Elaterium in Cardiac Dropsy, 44. 

in Constipation, 450. 

in Pleurisy, 336. 
Electricity in Constipation, 450. 

in Diabetes Insipidus, 195. 

in Gastralgia, 411. 

in Grave's Disease, 107. 

in Ileus, 435. 

in Malaria Spleen, 549. 

in Motor Insufficiency, 390. 

in Muscular Rheumatism, 165. 

in Neurasthenia, 405. 

in Palpitation, 68. 

in Urethritis, 255. 
Electric Baths in Bright's Disease, 218. 

in Pleurisy, 333. 

in Chronic Rheumatism, 171, 172. 
Electrization of Stomach, Technique of, 390. 
Embryocardia, 70. 
Emetics in Bronchitis, 281. 

in Capillary Bronchitis, 294. 

in Gastritis, 343. 
Emphysema, Pulmonary, 294-299. 
Empyema, 339, 340. 
Endemic Cretinism, 101. 

Dysentery, 558. 
Endocarditis, Acute, 49-51. 

in Pneumonia, 529. 

Septic, 49. 

Syphilitic, 50. 
Endogenous Uric Acid, 174. 
Enemata in Cholelithiasis, 504. 

in Constipation, 450. 

in Ileus, 429. 

Nutritive, 369-370. 
Energy, from Food, 113. 
Enteritis Membranous, 441-443. 
Enteroclysis in Dysentery, 560. 
Enteroliths After Oil Treatment, 500. 
Enzymes, see Ferments. 



Epidemic Dysentery, 558. 

Epididymitis, 253-254. 

Epigastric Pain in Aortic Insufficiency, 19. 

in Hepatic Stasis, 39. 
Epistaxis, 271-276. 
Epsom Salt, 44. 
Epstein, Cure for Obesity, 152. 
Equivalents for White Bread, 126, 127. 
Ergot Injections in Leukemia, 89. 

in Diabetes, 195. 

in Epistaxis, 275. 

in Gastric Ulcer, 376. 

in Hematuria, 201, 232. 

in Hemophilia, 98. 

in Hemoptysis, 310. 

in Intestinal Hemorrhage, 439. 

in Pulmonary Edema, 301, 302. 

in Purpura, 100. 
Ergotine in Gastric Ulcer, 376. 
Erigeron in Hematuria, 232. 
Erythrol Tetranitrate in Angina Pectoris, 65 

in Epistaxis, 274. 
Erysipelas Antitoxin in Leukemia, 89. 
Erythematous Stomatitis, 261. 
Eserine in Flatulency, 464. 
Ether in Heart Disease, 32. 

in Hemoptysis, 310. 

in Palpitation, 69. 

in Uremic Asthma, 241. 

Spray in Constipation, 449. 
Eucalyptol in Bronchitis, 285. 

in Pulmonary Gangrene, 306. 
Eucalyptus as Mouth Wash, 261. 

in Bronchitis, 284. 

in Malaria, 548. 

in Pseudo-leukemia, 93. 

for Inhalations, 306. 
Eudoxin in Intestinal Catarrh, 421. 
Euquinine in Malaria, 545. 
Europhen in Tetanus, 557. 
Exalgin in Gastralgia, 412. 
Exercise in Cholelithiasis, 499. 

in Chronic Nephritis, 222. 

in Constipation, 450. 

in Diabetes, 139. 

in Gastric Ulcer, 368. 

in Heart Disease, 22. 

in Hepatic Insufficiency, 495. 

in Intestinal Catarrh, 423. 

in Neurasthenia, 407. 

in Obesity, 150, 159. 

in Palpitation, 67. 

in Tuberculosis, 319. 

in Uric Acid Diathesis, 183. 
Exophthalmic Goitre, 104-109. 
Expectorants in Capillary Bronchitis, 294. 

Dangers in Heart Disease, 38. 

in Emphysema, 295. 

in Hemoptysis, 308. 

in Laryngitis, 276. 

in Tuberculosis, 328. 
Expression of Gastric Contents, 344. 
Exogenous Uric Acid, 174. 
Extractives in Compensated Heart Lesions, 



613 



Failing Compensation, 26-34. 
Fainting, in Aortic Insufficiency, 18. 
Fat, Caloric Value of, 113. 
Fattening Cure in Floating Kidney, 235. 
Fatty Degeneration of the Heart, 47-49. 

Heart in Obesity, 147. 
Fasting, in Heart Disease, 22. 
Fecal Obstruction of the Bowel, 424. 
Feeding, see Diet. 
Fel Bovis, see Bile. 
Fennel as a Carminative, 463. 
Ferments, Amylolytic, 366. 

Digestive in Chronic Gastritis, 364. 

in Achylia Gastrica, 401. 

in Hyposecretion, 401. 

Proteolytic, 364. 
Ferratin in Chlorosis, 85. 
Fetal Myxedema, 101. 
Fetor of Breath, 306. 

in Diabetes, 140. 
Fever Diet, 509-511. 

Treatment of, 507-509. 
Fibrinous Bronchitis, 285. 
Filaria, as Cause of Anemia, 72. 
Filipuncture in Aneurism, 60. 
Finsen Light in Smallpox, 584. 
Flatulency, 461-464. 

in Acute Peritonitis. 470. 
Floating Kidney, 234-236. 
Follicular Stomatitis, 261. 
Fomentations in Cystitis, 243. 

in Tuberculous Peritonitis, 482. 
Food, Composition of, 113-118. 
Foot Bath in Yellow Fever, 587. 
Footwear in Anemia, 79. 
Forced Feeding in Tuberculosis, 329. 
Formaldehyde in Night Sweats, 327. 
Formalin as Room Disinfectant, 575. 
Fowler's Solution in Asthma, 288. 

in Myocarditis, 49. 

in Pernicious Anemia, 7^. 

in Pseudo-leukemia, 91. 

in Purpura, 100. 

in Tuberculosis, 324. 
Franzensbad in Hepatic Hyperemia, 40. 
Fresh Air in Tuberculous Peritonitis, 481. 

in Smallpox, 584. 

Treatment of Tuberculosis, 313, 314. 
Fruit Cure in Uric Acid Diathesis, 181. 
Fumigation in Yellow Fever, 593. 
Furunculosis in Diabetes, 141. 

in Obesity, 149. 



Gall-duct Occlusion, 502. 

Gallop Rhythm, 70. 

Gall Stones, see Cholelithiasis. 

Stone Occlusion of the Bowel, 424. 
Galvano-cautery in Stomatitis, 261. 

puncture in Aneurism, 59. 

puncture in Leukemia, 89. 
Gangrene, Diabetic, 145. 
Gangrene of Lung, 303-306. 



Gangrenous Stomatitis, 261, 262. 
Gargles in Tonsillitis, 264. 
Gastralgia, 411. 

Gastric Atony, see Motor Insufficiency. 
Atrophy in Anemia, 72. 
Carcinoma, 378-384. 
Catarrh in Diabetes, 142. 
Dilatation, see Motor Insufficiency. 
Ectasy, see Motor Insufficiency. 
Hyposecretion, 398-401. 
Hyperchlorhydria, 393-398. 
Hyperesthesia, 411. 
Hypersecretion, 393-398. 
Lavage, 344-346. 
Neuroses, 401-412. 
Ulcer, 366-377. 
Gastritis, Acute, 343. 
Chronic, 355-366. 
Gastro-enterostomy in Gastric Carcinoma, 
378. 
in Gastric Ulcer, Z77- 
Gelatin in Aneurism, 58. 
in Gastric Ulcer, 376. 
in Hemophilia, 98. 
in Hemoptysis, 311. 
in Internal Hemorrhage, 440. 
in Scurvy, 96. 

Injections, Technique of, 58, 59. 
Gentian in Chronic Gastritis, 363. 
Ginger as a Carminative, 463. 
Gingivitis in Diabetes, 140. 
Glandular Fever, Recurrent, 90. 
Glauber Salt, 44. 
Glottis Edema, 240. 
Gluten Bread, 126. 
in Obesity, 158. 
Glutoid Capsule, 417. 
Glycerin as a Mouth Wash, 260. 
Enema in Constipation, 451. 
in Cholelithiasis, 501. 
in Epididymitis, 253. 
in Nephrolithiasis, 231. 
Glycosuria, Alimentary, 146. 
Diabetic, see Diabetes, 
from Thyroid, 160. 
Goitre, Exophthalmic, 104-109. 

Simple, 109. 
Gomenol in Cystitis, 246. 
Gonorrhea, Female, 252. 

see Urethritis. 
Gonosan in Cystitis, 244. 

in Urethritis, 252. 
Gout, 173-188. 

Abarticular, 173 f. 
Acute Attacks of, 186-188. 
Atypical, 173 f. 
Cardiac, 185. 
Cerebral, 185. 
Cutaneous, 185. 
Incomplete, 173 f. 
Irregular, 173 f. 
Retrocedent, 185, 186. 
Rheumatic, 161. 
Vesical, 185. 
G'ranatum for Tape Worm, 465. 



6i4 



INDEX 



Grave's Disease, 104-109. 

Surgical Treatment, 108. 
Gray Oil in Syphilis, 600. 
Green Soap in Tuberculous Peritonitis, 482. 
Guaiac in Tonsillitis, 263, 264. 

in Rheumatic Fever, 552. 
Guaiacol in Bronchitis, 284. 

in Cystitis, 246. 

in Epididymitis, 253. 

in Chronic Rheumatism, 169. 

in Tuberculosis, 324. 
Gum Lesions in Diabetes, 140. 
Gumma in Syphilis, 596. 

K 

Habitual Constipation, 446. 
Hamamelis in Hemoptysis, 310. 

in Internal Hemorrhage, 440. 
Hardening in Rhinitis, 266. 

of Tuberculous Patients, 315. 
Haustus Colchici, 187. 
Hay Fever, 269-271. 
Headache in Aortic Insufficiency, 18. 
Heart Disease, 17-70. 

Failure in Typhoid Fever, 538. 

Tonics as Diuretics, 43. 

Tonics in Acute Nephritis, 202, 204. 

Tonics in Angina Pectoris, 64. 

Tonics in Capillary Bronchitis, 294. 

Tonics in Emphysema, 295. 

Tonics in Epistaxis, 273. 

Tonics in Hemoptysis, 307, 308. 

Tonics in Palpitation, 67. 

Tonics in Pneumonia, 525. 

Tonics in Pulmonary Edema, 300. 

Tonics in Pulmonary Infarct, 305. 

Tonics in Uremia, 240. 

Tonics, Indications for, 27-32. 
Helmitol in Cystitis, 244. 
Hematemesis in Gastric Carcinoma, 383. 

in Gastric Ulcer, 375, 376. 

in Heart Disease, 40. 
Hematoporphyrinuria after Sulphonal, 35. 
Hematuria, 232. 

in Acute Nephritis, 201. 
Hemoglobin in Chlorosis, 85. 

in Pernicious Anemia, 74. 
Hemophilia, 95, 97, 98. 
Hemoptysis, 306-312. 
Hemorrhage as Cause of Anemia, 76, 78. 

from the Bowel, 439, 440. 

from the Colon, 440. 

from the Stomach, see Hematemesis. 

from the Rectum, 440. 

in Typhoid Fever, 538. 
Hemorrhagic Diathesis, 95-100. 
Hemorrhoids in Obesity, 149. 
Hemostatics in Gastric Ulcer, 376. 
Hepatitis, Chronic, 488, 497. 

Syphilitic, 488-497. 
Hepatic Cirrhosis, 488, 497. 

Insufficiency, 488, 497. 

Insufficiency in Bright's Disease, 206. 
Herba Cochleariae in Scurvy, 96. 
Herniaria in Acute Nephritis, 203. 



in Cystitis, 244. 
Heroin in Bronchitis, 280. 

in Pulmonary Hyperemia, 38. 
Hetol in Tuberculosis, 324, 328. 
Hiccup in Acute Peritonitis, 470. 
Hirschfeldt Cure for Obesity, 152. 
Hodgkin's Disease, 90. 
Hoffman's Anodyne in Heart Disease, 32. 
Homburg in Obesity, 158. 
Home Treatment of Tuberculosis, 313, 314. 
Horseradish in Scurvy, 96. 
Hot Air Baths in Acute Nephritis, 203. 

in Bright's Disease, 218. 

in Cardiac Dropsy, 42. 

in Chronic Rheumatism, 171. 
Hydragogue Cathartics, see Laxatives. 
Hydrastis in Epistaxis, 274. 

in Gastric Ulcer, ^76- 

in Hemophilia, 98, 232. 

in Hemoptysis, 311. 

in Internal Hemorrhage, 439. 

in Purpura, 100. 
Hydrochloric Acid in Achylia Gastrica, 401. 

in Chronic Gastritis, 356, 359-361. 

in Diabetes Phosphaticus, 234. 

in Gastric Carcinoma, 381. 

in Hyposecretion, 401. 

in Intestinal Catarrh, 416. 
Hydrogen Peroxide in Scurvy, 96. 

in Stomatitis, 262. 
Hydrotherapy, General Principles of, 2i6f. 

in Acute Nephritis, 203. 

in Appendicitis, 478. 

in Bright's Disease, 216-221. 

in Bronchitis, 284. 

in Capillary Bronchitis, 291. 

in Chlorosis, 82. 

in Constipation, 448. 

in Diphtheria, 543. 

in Fevers, 508. 

in Grave's Disease, 107. 

in Hepatic Cirrhosis, 495. 

in Hepatic Insufficiency, 495, 496. 

in Influenza, 561. 

in Intestinal Catarrh, 422. 

in Measles, 572. 

in Motor Insufficiency, 391. 

in Neurasthenia, 404, 405. 

in Obesity, 160. 

in Parotitis, 566. 

in Pernicious Anemia, 72. 

in Rachitis, 193. 

in Rheumatic Fever, 553. 

in Scarlatina, 570. 

in Tuberculosis, 326. 

in Typhoid Fever, 534-537. 

in Uric Acid Diathesis, 184. 

in Yellow Fever, 588, 589. 
Hygiene of Sick Room, 516-520. 

in Measles, 572. 

in Osteomalacia, 194. 

in Parotitis, 566. 

in Pertussis, 562. 

in Rachitis, 189. 

in Chronic Rheumatism, 166. 

in Scarlatina, 567. 568. 



6i5 



in Scurvy, 96. 

in Smallpox, 574, 575. 

in Yellow Fever, 587. 
Hyoscine in Grave's Disease, 107. 
Hyoscyamus in Asthma, 289, 290. 

in Bronchitis, 280. 

in Gout, 187. 

in Pulmonary Edema, 301. 
Hyperacidity in Gastric Ulcer, 372. 
Hyperchlorhydria, Gastric, 393-398. 

Neurotic, 410. 
Hyperemia of Brain, 34-38. 

of Lungs, 38. 
Hyperesthesia, Gastric, 411. 
Hypersecretion, Gastric, 393, 398. 
Hyperthyroidism, 102-103. 
Hypertrophic Cirrhosis of the Liver, 488-497. 
Hypnosis in Palpitation, 69. 
Hypnotics in Heart Disease, 34. 
Hypochlorhydria, see Hyposecretion. 

Neurotic, 410. 
Hypochylia, see Achylia. 
Hypodermic Purgation, 456. 
Hypodermoclysis in 7\cute Peritonitis, 469. 

in Ileus, 436. 

in Pernicious Anemia, 76. 
Hypophosphites in Tuberculosis, 325. 
Hyposecretion, Gastric, 398-401. 

I 

Ice-bag in Appendicitis, 478. 
.in Aortic Insufficiency, 19. 

in Cholelithiasis, 504. 

in Endocarditis, 50. 

in Hepatic Hyperemia, 39. 

in Hemoptysis, 309. 

in Palpitation, 68. 

in Pleurisy, 334. 

in Rheumatic Fever, 553. 
Ichthoform in Intestinal Catarrh, 417. 
Ichthyol in Urethritis, 255. 
Icterus, Catarrhal, 485-488. 
Idiosyncrasy against salicylates, 551. 
Idiotism, Myxedematous, 101. 
Ileus, 423-437. 
Immobilization of Joints in Rheumatism, 

167. 
Incision in Cardiac Dropsy, 45. 
Indican, 207. 

Infantile Myxedema, 101. 
Infarct, Pulmonary, 303-306. 
Influenza, 560, 561. 
Infusion in Acute Peritonitis, 469. 

in Uremia, 242. 
Inhalations in Bronchitis, 280. 

in Laryngitis, 277. 

in Pertussis, 565. 

in Tonsillitis, 264. 

in Tuberculosis, 327. 
Injections in Chronic Rheumatism, 168. 

in Cystitis, 245, 246. 

in Epistaxis, 272. 

in Lung Abscess, 305. 

in Pulmonary Gangrene, 306. 

in Syphilis, 599. 



in Urethritis, 250. 
Insomnia in Heart Disease, 34. 

in Pneumonia, 526. 

in Tuberculosis, 331. 
Insomnia, Veronal in, 36. 
Instillations in Cystitis, 245. 
Institution Treatment of Neurasthenia, 404^ 

of Tuberculosis, 313. 
Insufflations in Laryngitis, 278. 

in Pertussis, 565. 
Insufficiency of the Cardia, 410. 

of the Pylorus, 410. 
Intermittent Pulse, 70. 
Intertrigo in Obesity, 149. 
Interval Operation in Appendicitis, 479-481- 
Intestinal Antisepsis in Bright's Disease, 2o6> 

in Diabetes, 137. 

in Hepatic Insufficiency, 493. 

in Intestinal Catarrh, 416, 417. 

Catarrh, Acute, 413-418. 

Catarrh, Chronic, 418-423. 

Hemorrhage, 439, 440. 

Occlusion, see Ileus. 

Parasites, 464-468. 

Parasites in Anemia, 71, j6. 

Stenosis, see Ileus. 

Ulcer, 437-440. 
Intestine, Passive Congestion of, 40, 41. 
Intubation in Diphtheria, 544. 

in Pertussis, 564. 
Intussusception of the Bowel, 424. 
Inunctions in Acute Peritonitis, 470. 

in Diphtheria, 543. 

in Phlebitis, 304. 

in Tuberculous Peritonitis, 482. 

in Syphilis, 598. 
Iodides in Aneurism, 58. 

in Angina Pectoris, 65. 
' in Arterio-sclerosis, 55. 

in Diabetes, 136. 

in Endocarditis, 51. 

in Gout, 188. 

in Pulmonary Edema, 300. 

in S3'philis, 602. 
Iodine in Appendicitis, 478. 

in Bronchitis, 281. 

in Grave's Disease, 108. 

in Leukemia, 88. 

in Muscular Rheumatism, 165. 

in Pleurisy, 334. 

in Vomiting, 240. 
Iodoform in Cystitis, 246. 

in Pseudo-leukemia, 92. 
Iodoglobulin, 104. 
Iodo-glycerin in Palpitation, 68. 
Iodol in Urethritis, 256. 
Iodothyrin, 104. 
Ipecac in Acute Gastritis, 343. 

in Bronchitis, 282, 284. 

in Dysentery, 559. 

in Heart Disease, 38. 

in Hemoptysis, 308. 
Iron Cacodylate in Pseudo-leukemia, 92, 

Citrate in Chlorosis, 84. 

in Anemia, 80. 



6i6 



in Chlorosis, 83. 

in Diabetes, 137. 

in Dysentery, 560. 

in Grave's Disease, 107. 

in Hepatic Insufficiency, 495. 

in Intestinal Hemorrhage, 440. 

in Osteomalacia, 194. 

in Pernicious Anemia, 74. 

in Pertussis, 564. 

in Pseudo-leukemia, 92. 

in Purpura, 100. 

in Scurvy, 96. 

in Simple Anemia, 79, 80. 

in Smallpox, 583. 

Peptonates in Chlorosis, 85. 
Iron Waters in Anemia, 80. 

in Chlorosis, 85. 
Irrigations in Appendicitis, 476. 
Irrigation of the Bowel in Ileus, 428. 

in Acute Gastritis, 346. 

in Constipation, 450. 

in Diphtheria, 542. 

in Icterus, 487. 

in Intestinal Catarrh, 414, 422. 

in Flatulency, 464. 
Irritability in Aortic Insufficiency, 18. 
Isodynamics, Law of, 114. 
Isolation in Smallpox, 574. 
Itching in Icterus, 488. 



Jaborandi in Cardiac Dropsy, 42. 
lalap in Cardiac Dropsy, 44. 

in Constipation, 454. 

in Cystitis, 243. 

in Pleurisy, 336. 
Jambul in Diabetes, 135. 
Jaundice, see Icterus. 
Juniper Oil in Pyelitis, 223. 

K 

Keratinized Pills, 417. 
Kidneys, Passive Hyperemia of, 41. 
Kinking of the Bowel, 425. 
Kino in Intestinal Catarrh, 420. 
Kissingen, in Hepatic Hyperemia, 40. 
in Obesity, 158. 



ILactic Acid in Arterio-sclerosis, 54. 

in Diabetes, 137. 

in Rachitis, 190. 
Lactophenine in Gastralgia, 412. 

in Rheumatic Fever, 552. 

in Tuberculosis, 326. 

in Typhoid Fever, 532. 
Lacto-phosphates in Rachitis, 192. 
Lacunar Tonsillitis, 263. 
Laryngitis, Acute, 276-279. 
Laudanum, see Opium. 
Lavage, Gastric, 344-346. 

in Achylia Gastrica, 400. 

in Gastric Carcinoma, 381, 382 

in Hyperchlorhydria, 396. 

in Hyposecretion, 400. 



Lavage in Ileus, 427-428. 

in Motor Insufficiency, 388-389. 

in Palpitation, 69. 

in Vomiting of Uremia, 240. 

of Renal Pelvis, 224-226. 
Lavender Oil for Inhalation, 306. 
Laxatives in Acute Gastritis, 346. 

in Anemia, 241. 

in Cholelithiasis, 504. 

in Constipation, 452-456. 

in Dysentery, 559. 

in Flatulency, 462. 

in Ileus, 433. 

in Mucous Colitis, 442, 443. 

in Pertussis, 563. 
Lead Acetate in Cystitis, 247. 

in Gastric Ulcer, 376. 

in Hemophilia, 98. 

in Hemoptysis, 310. 

in Intestinal Hemorrhage, 440. 

in Urethritis, 251. 

as Cause of Arterio-sclerosis, 53. 

Asthma, 286. 
Leeching, Anal, 40. 

in Appendicitis, 478. 

in Cerebral Hyperemia, 36. 

in Epistaxis, 276. 

in Gout, 187. 

in Pleurisy, 333. 

in Pneumonia, 524. 

in Pulmonary Edema, 303. 

in Tonsillitis, 264. 

Technique of, 36, 37. 
Lemons in Hemophilia, 97. 
Leucocytes in Appendicitis, 474. 
Leucocytic Leukemia, 87. 
Leucocytosis in Pneumonia, 525. 
Leukanemia, 86. 
Leukemia, 86-89. 

Leucocytic, 87. 

Lymphatic, 87. 

Lymphocytic, 87. 

Myelogenous, 87. 

Splenic, 87. 
Leiter Coil, Description of, 19. 

in Appendicitis, 478. 

in Aortic Insufficiency, 19. 

in Cholelithiasis, 503. 

in Diphtheria, 542. 

in Endocarditis, 50. 

in Gastric Ulcer, 368. 

in Ileus, 435. 

in Pericarditis, 51. 

in Tonsillitis, 263. 
Levulose in Coma, 144. 

in Diabetes, 138. 
Ligation of Extremities in Epistaxis, 273. 

in Aneurism, 61. 

in Hemoptysis, 310. 
Lime Salts in Rachitis, 190. 

Water in Bright's Disease, 211. 

Water in Bronchitis, 285. 

Water in Chronic Gastritis, 358. 

in Rachitis, 192. 
Liniments in Aneurism, 61. 



617 



in Flatulency, 464. 

in Gout, 186. 

in Pneumonia, 524. 

in Chronic Rheumatism, 167, 168. 

in Muscular Rheumatism, 165. 
Linseed in Cystitis, 243. 
Lithemia, 173 f. 

Lithium Salts in Nephrolithiasis Urica, 230. 
Liquids in Diabetes, 132. 
Liquorice in Bronchitis, 283. 
Liquid Restriction, see Drink Restriction. 
Liver, Cirrhosis of, 488-497, 

Extract in Diabetes, 137. 

Extract in Hepatic Cirrhosis, 496. 

Passive Hyperemia of, 38. 
Lobelia in Asthma, 289, 290. 
Lockjaw, see Tetanus. 
Lotions in Gout, 186. 
Lozenges in Tuberculosis, 328. 
Lues, see Syphilis. 

Lumbar Puncture in Uremic Attack, 242. 
Lymphatic Leukemia, 87. 
Lymph Gland Extract in Leukemia, 88. 
Lymphocytic Leukemia, 87. 
Lysidin in Nephrolithiasis, 231. 

M 

Magnesia Usta in Flatulency, 463. 

in Hyperchlorhydria, 397. 

in Gastric Ulcer, 372. 
Magnesium Citrate in Cystitis, 243. 

Sulphate, 44. 

"Sulphate in Hemophilia, 98. 

Sulphate in Hypodermic Purgation, 456. 

Sulphate in Muscular Rheumatism, 164. 

Sulphate in Tonsillitis, 263. 
Malakin in Rheumatic Fever, 551. 
Malaria, 544, 549. 

as Cause of Anemia, ^2. 
Malarial Diarrhea, 413, 458. 
Male Fern for Tape Worm, 465. 
Manganese in Chlorosis, 85. 
Marienbad in Diabetes, 136. 

in Hepatic Hyperemia, 40. 

in Intestinal Catarrh, 421. 

in Obesity, 158. 
Maritime Prophylaxis in Yellow Fever, 593. 
Marriage in Hemophilia, 97. 
Marmorek's Serum in Scarlatina, 568. 
Massage, Effect on Blood Pressure, 23. 

Effect on Circulation, 23. 

Effect on Respiration, 23. 

of the Heart, 23, 24. 

of the Bowel in Ileus, 434. 

of the Stomach, 390. 

in Aneurism, 58. 

in Appendicitis, 478. 

in Cardiac Dropsy, 42. 

in Chlorosis, 82. 

in Cholelithiasis, 499. 

in Chronic Nephritis, 222. 

in Chronic Rheumatism, 172. 

in Constipation, 448. 

in Diabetes, 139. 

in Gout, 187. 



in Heart Disease, 23. 

in Muscular Rheumatism, 165. 

in Neurasthenia, 405. 

in Obesity, 159. 

in Phlebitis, 304. 

in Uric Acid Diathesis, 183. 

Swedish, 23. 
Measles, 571-573- 
Megaloblasts, 71. 
Megalocytes, 71. 
Megalogastria, 384. 
Membranous Enteritis, 441-443. 
Menthol as Mouth Wash, 260. 

in Aneurism, 61. 

in Hay Fever, 270. 

in Intestinal Catarrh, 416. 

in Pruritus, 488. 

in Rhinitis, 258, 269. 

in Tonsillitis, 264. 
Mercurial Purgatives. 453. 

Stomatitis, 261, 262. 
Mercurialism in Syphilis, 601. 
Mercurol in Urethritis, 255. 
Mercury Baths in Syphilis, 599. 

Bichloride in Cystitis, 246. 

in Diabetes, 136. 

in Ileus, 427. 

in Syphilis, 595. 

Injections in Syphilis, 599. 

Inunctions in Diphtheria, 543. 

Inunctions in Syphilis, 598. 

Ointment in Tuberculous Peritonitis, 482. 

Plasters in Syphilis, 599. 
Meteorism in Ileus, 435. 

in Pneumonia, 528. 

in Typhoid Fever, 538. 

see Flatulency. 
Methylene Blue in Malaria, 548. 

in Pyelitis, 224. 
Milk, as a Diuretic in Acute Nephritis, 202. 

Cure in Diabetes, 129. 

Diet in Failing Compensation, 27. 

Diet in Renal Congestion, 41. 

Powder, 370. 

Sugar as a Diuretic, 43. 
Mineral Acids in Hemophilia, 97. 

Waters in Bright's Disease, 210. 

Waters in Bronchitis, 289. 

Waters in Cholelithiasis, 498. 

Waters in Chronic Gastritis, 357, 358. 

Waters in Chronic Nephritis, 210. 

Waters in Chronic Rheumatism, 170. 

Waters in Constipation, 455. 

Waters in Diabetes, 136. 

Waters in Emphysema, 297. 

Waters in Hyperchlorhydria, 396, 398. 

Waters in Icterus, 486, 487. 

Waters in Intestinal Catarrh, 421. 

Waters in Hepatic Hyperemia, 40. 

Waters in Nephrolithiasis, 230. 

Waters in Obesity, 158. 

Waters in Pernicious Anemia, 74. 

Waters in Uremia, 238. 

Waters in Uric Acid Diathesis, 182. 
Mitral Insufficiency, 17. 



6i8 



Stenosis, 17. 
Mixed Treatment in Syphilis, 603. 
Morbus Maculosus, 98. 
Morphine Habit, 18. 

in Acute Gastritis, 347. 

in Aneurism, 61. 

in Angina Pectoris, 64. 

in Asthma, 289. 

in Bronchitis, 283, 284. 

in Emphysema, 299. 

in Epistaxis, 275. 

in Gastralgia, 412. 

in Gastric Ulcer, 376. 

in Hay Fever, 270. 

in Hemoptysis, 309. 

in Muscular Rheumatism, 164. 

in Palpitation, 69. 

in Pericarditis, 51. 

in Pleurisy, 335. 

in Pneumonia, 524. 

in Pulmonary Infarct, 304. 

in Renal Colic, 232. 

in Tetanus, 557. 

in Tuberculosis, 328. 

in Uremic Attack, 242. 
Motor Insufficiency of the Stomach, 384-392. 
Mosquitoes and Malaria, 549. 

and Yellow Fever, 590-592. 
Mouth Washes, 260. 
Mucous Colic, 441-443. 
Mud Baths in Chronic Rheumatism, 171. 
Mumps, see Parotitis, 566, 567. 
Muscular Rheumatism, 162, 163-165. 
Mustard Foot Bath in Rhinitis, 268. 

in Chronic Gastritis, 363. 

Plaster, 333. 
Myelogenous Leukemia, 87. 
Myocarditis, 47-49. 

Acute, 48. 

Chronic, 49. 

in Articular Rheumatism, 48. 
Myrrh in Scurvy, 96. 
Myrtol in Pulmonary Gangrene, 306. 
Myxedema, 101-104. 
Myxedematous Idiotism, 101. 

N • 

Naphthalin in Dysentery, 559. 

in Thread Worms, 467. 
Narcotics in Bronchitis, 285. 

in Capillary Bronchitis, 294. 

in Gastric Ulcer, 375. 

in Intestinal Catarrh, 417. 

in Tuberculosis, 328. 
Nauheim in Heart Disease, 23. 

in Obesity, 159. 
Nephritis, 197-222. 

Acute, 198-204. 

Interstitial, 197, 204-222. 

Parenchymatous, 197, 204-222. 

Scarlatinal, 571. 
Nephrolithiasis, 226-234. 

Oxalurica, 233. 

Phosphatica, 233, 234. 

Urica, 227-232. 



Nervous Belching, 408. 

Diarrhea, 459-461. 

Dyspepsia, 412. 

Vomiting, 409. 
Neuralgia in Diabetes, 143. 

see Antineuralgics. 
Neurasthenia, in Aortic Insufficiency, 18. 

see Gastric Neuroses. 
Neuroses, Gastric, 401-412. 
Night Sweats in Tuberculosis, 326. 
Nitrites in Angina Pectoris, 64. 

in Arterio-sclerosis, 55. 

with Digitalis, 30. 
Nitroglycerin in Angina Pectoris, 64 

in Arterio-sclerosis, 56. 

in Epistaxis, 274. 

in Pneumonia, 522. 

with Digitalis, 30. 
Noma, 262. 

Nose Bleed, see Epistaxis. 
Notification in Smallpox, 573-574. 
Nuclein, as Source of Uric Acid, 173, 174. 
Nursing, Directions for, 517, 519. 
Nursing, in Yellow Fever, 590. 
Nutmeg as a Carminative, 463. 

in Chronic Gastritis, 363. 
Nutrition, Laws of, 113-118. 
Nutritive Enemata, 369, 370. 
Nux Vomica in Chronic Gastritis, 363. 

in Motor Insufficiency, 391. 

in Palpitation, 68. 



Oatmeal Cure in Diabetes, 129. 
Obesity, 147-161. 

and Emphysema, 298. 

and Uric Acid Diathesis, 185. 

Complication of, 147-149. 
Occlusion of the Bowel, see Ileus. 
Oertel Cure, 23. 

for Obesity, 152. 
Oertel's Theory of Drink Restriction, 20. 
Oidium Albicans, 261. 
Oil Cure in Motor Insufficiency, 391. 

Injections in Constipation, 451. 

Injections in Ileus, 429. 

Injections in Mucous Colitis, 442. 
Ointments in Acute Nephritis, 200. 

in Aneurism, 61. 

in Chronic Rheumatism, 168. 
Oleoresins in Tuberculosis,' 328. 
Olive Oil in Cholelithiasis, 500. 

in Gastric Ulcer, 375. 

in Nephrolithiasis, 232. 
Open Air Treatment in Tuberculosis, 3x3, 

314. 
Opiates in Bronchitis, 2.80. 

in Cholelithiasis, 503. 

in Hemoptysis, 307, 310. 

Contraindications to, 35. 

Danger in Heart Disease, 34. - 

Danger in Pulmonary Hyperemia, 38. 

Danger in Renal Disease, 18. 

in Acute Peritonitis, 469. 

in Aortic Insufficiency, 18. 



6lQ 



in Appendicitis, 476-478. 

in Bronchitis, 283, 284. 

in Cerebral Ischemia, 18. 

in Cystitis, 243. 

in Diabetes, 133-134. 

in Diarrhea, 459. 

in Epistaxis, 275. 

in Gastric Ulcer, 376. 

in Hay Fever, 270. 

in Hemophilia, 98. 

in Ileus, 430-432. 

in Intestinal Catarrh, 417, 422. 

in Intestinal Hemorrhage, 439. 

in Intestinal Ulcer, 439. 

in Mucous Colitis, 442. 

in Nervous Diarrhea, 461. 

in Nervous Dyspnea, 18. 

in Renal Colic, 232. 

in Rhinitis, 268. 

in Spastic Constipation, 446. 

in Tuberculosis, 328. 

in Uremia, 240. 

in Uremic Attack, 242. 
Orchitis, see Epididymitis. 
Orexine in Chronic Gastritis, 363. 
Organic Iron Preparations, 84. 

Peroxides as Intestinal Antiseptics, 207. 
Organotherapy in Hepatic Cirrhosis, 496. 
Orphol in Intestinal Catarrh, 421. 
Orthoform in Gastric Ulcer, 372, 374. 
Orthopedics of Rachitis, 193. 
Orthopedic Treatment in Chronic Rheuma- 
tism, 172. 
Osteomalacia, 193, 194. 
Otitis in Measles, 573. 

in Scarlatina, 571. 
Oxidizing Treatment in Hepatic Insufficien- 
cy, 495- 
Oxygen in Capillary Bronchitis, 294. 

in Coma, 145. 

in Emphysema, 299. 

in Pulmonary Infarct, 304. 

in Leukemia, 88. 

in Pneumonia, 525. 

in Uremic Asthma, 241. 
Oxyuris Vermicularis, see Thread Worms. 



Pain in Appendicitis, 473. 

in Pneumonia, 523. 
Palpitation, 65-69. 

in Aortic Insufficiency, 19. 
Pancreas Preparations in Diabetes, 137. 
Pancreatin in Bright's Disease, 212. 

in Chronic Gastritis, 365. 
Pancreon in Chronic Gastritis, 365. 
Papain in Chronic Gastritis, 365. 
Paquelin Cautery in Stomatitis, 261. 
Paracentesis of Abdomen, Technique of, 46, 
47- 

in Pulmonary Edema, 303. 

in Dropsy, 46. 

of Pericardium, 47, 52, 53. 

of Pleura, 47. 
Paradox Pulse, 70. 



Paraldehyde in Insomnia, ^6. 
Parasites, Intestinal, 464-468. 
Parotitis, 566, 567. 
Peliosis Rheumatica, 98. 
Pelletierine for Tape Worm, 465. 
Pepo for Tape Worm, 465. 
Pepper in Chronic Gastritis, 363. 
Peppermint as a Carminative, 463. 

for Mouth Wash, 261. 
Pepsin in Achylia Gastrica, 401. 

in Chronic Gastritis, 364. 

in Hyposecretion, 401. 
Peptonate of Iron, 85. 
Perforation of the Bowel in Typhoid Fever, 

539- 
Perforative Peritonitis, 468. 
Pericardial Exudates, 52-54. 
Pericardiotomy, 52. 
Pericarditis, 51-53. 

in Pneumonia, 527. 
Peritonitis, Acute Circumscribed, 471-481. 

Acute Diffuse, 468-471. 

Chronic, 481-484. 

Tuberculous, 481-484. 
Peritonsillar Abscess, 263. 
Perityphlitis, 471-481. 
Peronin in Bronchitis, 280. 
Pertussis, 561-566. 

Peru Balsam in Bronchitis, 282, 284. 
Petit's Triangle, 201. 
Pharyngitis, Acute, 265, 269. 
Phenacetin in Diabetes, 134. 

in Gout, 188. 

in Malaria, 548. 

in Muscular Rheumatism, 164. 

in Pertussis, 565, 567. 

in Rheumatic Fever, 552. 

in Tuberculosis, 326. 
Phenols in Diabetes, 137. 
Phlebitis, 304. 

Phosphates in Tuberculosis, 325. 
Phosphoric Acid in Diabetes Phosphaticus, 

234. 
Phosphorus in Leukemia, 88. 

in Osteomalacia, 193. 

in Pseudo-leukemia, 91. 

in Rachitis, 193. 
Physiological Constipation, 444. 
Physostigmine in Flatulency, 464. 
Pichi Pichi in Cystitis, 244. 
Pilocarpine in Acute Nephritis, 203. 

in Bronchitis, 279. 

in Cardiac Dropsy, 42. 

in Croup, 543. 
Piperazin in Nephrolithiasis, 231. 
Plasmon Bread, 126. 
Plasters in Angina Pectoris, 64. 

in Bronchitis, 281. 

in Muscular Rheumatism, 165. 

in Pericarditis, 51. 

in Pleurisy, 333. 
Pleuritis, 331-341. 

Plugging of Nares in Epistaxis, 273. 
Pneumonia, 51 1-53 1. 

Jacket, 524. 






620 



Pneumatic Chamber, 297. 
Pneumothorax, 339, 340. 
Pneumotomy, 305. 
Popophyllum in Cardiac Dropsy, 44. 

in Constipation, 454. 

in Hepatic Congestion, 40. 
Polyuria, Hysterical, 195. 

Symptomatic, 194. 
Pomegranate for Tape Worm, 465. 
Potassium Acetate in Acute Nephritis, 202. 

Acetate in Bronchitis, 280. 

Acetate in Pleurisy, 336. 

Bromide in Asthma, 289. 

Bromide in Tetanus, 557. 

Bromide in Valve Lesions, 35. 

Carbonate in Bronchitis, 280. 

Chlorate in Salivation, 43. 

Chlorate in Scurvy, 96. 

Chlorate in Stomatitis, 261. 

Chlorate in Thrush, 262. 

Citrate in Bronchitis, 280. 

Iodide in Angina Pectoris, 65. 

Iodide in Arterio-sclerosis, 55. 

Iodide in Asthma, 288. 

Iodide in Bronchitis, 285. 

Iodide in Diabetes, 136. 

Iodide in Pneumonia, 522, 524. 

Iodide in Pseudo-leukemia, 91. 

Iodide in Rheumatic Fever, 552. 

Iodide in Syphilis, 602. 

Nitrate in Asthma, 289, 290. 

Nitrate in Angina Pectoris, 65. 

Permanganate in Chronic Gastritis, 356. 

Permanganate in Scurvy, 96. 

Permanganate in Stomatitis, 262. 

Permanganate in Thrush, 262. 
Potato Cure in Diabetes, 129. 
Poultices, 39. 

in Angina Pectoris, 64. 

in Appendicitis, 478. 

in Muscular Rheumatism, 165. 

in Pericarditis, 51. 

in Pleurisy, 334. 

in Tonsillitis, 264. 

in Tuberculous Peritonitis, 482. 
Predigested Foods in Icterus, 486. 
Pregnancy as a Cause of Anemia, 72. 
Priessnitz Compress in Acute Gout, 346. 

in Acute Nephritis, 203. 

in Appendicitis, 478. 

in Bronchitis, 281. 

in Constipation, 449. 

in Diarrhea, 459. 

in Gastric Ulcer, 368. 

in Neurasthenia, 404. 

in Pericarditis, 51. 

in Pleurisy, 334. 

in Tonsillitis, 263. 

in Tuberculous Peritonitis, 482. 
Progressive Pernicious Anemia, 71. 
Prophylaxis of Acute Nephritis, 198. 

of Angina Pectoris, 62. 

of Asthma, 288. 

of Bronchitis, 279. 

of Chlorosis, 81. 



of Cholelithiasis, 497, 498. 

of Chronic Rheumatism, 166. 

of Cystitis, 243. 

of Diabetes, 145. 

of Diabetic Coma, 144. 

of Diabetic Gangrene, 145. 

of Diarrhea, 456. 

of Endocarditis, 49. 

of Gastric Ulcer, 367. 

of Gastritis, 355. 

of Gonorrheal Urethritis, 248, 249. 

of Gout, 188. 

of Gouty Attack, 186. 

of Hay Fever, 270. 

of Hemophilia, 97. 

of Hemoptysis, 307, 308. 

of Infectious Diseases, 507. 

of Malaria, 549. 

of Measles, 571. 

of Muscular Rheumatism, 163. 

of Nephrolithiasis, 227. 

of Palpitation, 67. 

of Pertussis, 561-562. 

of Pharyngitis, 266. 

of Pneumonia, 512-516. 

of Pulmonary Infarct, 303. 

of Pyelitis, 222. 

of Pyonephrosis, 222. 

of Rachitis, 189. 

of Rheumatoid Arthritis, 166. 

of Rhinitis, 266. 

of Scarlatina, 567, 568. 

of Scurvy, 95, 96. 

of Smallpox, 573-579- 

of Stomatitis, 260. 

of Tetanus, 554. 

of Tonsillitis, 263. 

of Uremic Attacks, 238. 

of Yellow Fever, 590-593. 
Prostatitis, 253. 
Protargol in Urethritis, 250. 
Proteids, Caloric Value of, 113. 
Proteolytic Ferments, 364. 
Pruritus Ani, 467. 

in Diabetes, 141. 

in Icterus, 488. 
Pseudo-Angina Pectoris, 65. 

-Hay Fever, 269, 270. 

-Leukemia, 89-93. 

-Rheumatism, 161. 
Psychic Treatment in Bright's Disease, 219. 
Psychoses of Heart Disease, 34. 
Ptyalin in Chronic Gastritis, 366. 
Ptyalism, 261, 262. 
Pulmonary Abscess, 303-306. 

Edema, 299-303. 

Edema in Pneumonia, 528. 

Edema in Uremia, 240. 

Emphysema, 294-299. 

Gangrene, 303-306. 

Infarct, 303-306. 

Insufficiency, 17. 

Stenosis, 17. 

Tuberculosis, 312-331. 
Pulse in Appendicitis, 473. 



621 



Pumpkin Seed for Tape Worm, 465, 466. 
Puncture of the Bowel in Flatulency, 464. 

in Ileus, 435. 
Purgation in Icterus, 485. 
Purgatives, Mercurial, 44. 

see Laxatives. 

Vegetable, 44. 
Purging in Appendicitis, 478. 

in Uremia, 237. 
Purin Bases, 20, 182, 206 f. 
Purpura, 95, 98-100. 

Rheumatica, 98. 

Simplex, 98. 
Putrid Bronchitis, 284. 
Pyelitis, 222, 224. 
Pyloric Insufficiency, 410. 
Pylorospasm, 408. 
Pyoktanin in Cystitis, 247. 
Pyonephrosis, 222-224. 
Pyorrhea in Diabetes, 140. 
Pyramidon in Gastralgia, 412. 

in Tuberculosis, 326. 



Quarantine in Smallpox, 574. 
Quassia in Chronic Gastritis, 363. 

for Thread Worms, 467. 
Quinic Acid Salts in Gout, 188. 
Quinine Bimuriate in Malaria, 545. 

Citrate in Chlorosis, 84. 

Hydrobromate in Heart Disease, 19. 

-Idiosyncrasy Against, 547. 

in Aortic Insufficiency, 19. 

in Chronic Rheumatism, 169. 

in Diabetes, 137. 

in Diarrhea, 413. 

in Dysentery, 560. 

in Endocarditis, 50. 

in Fever, 509. 

in Influenza, 560. 

in Leukemia, 88. 

in Malaria, 544-548. 

in Muscular Rheumatism, 164. 

in Myocarditis, 48. 

in Pericarditis, 51. 

in Pertussis, 565. 

in Pseudo-leukemia, 91. 

in Rhinitis, 268. 

in Typhoid Fever, 532. 

in Scurvy, 96. 

in Smallpox, 583. 

Sulphate in Bronchitis, 279. 

Valerianate in Heart Disease, 19. 



Rachitis, 188-193. 

Radium in Urethritis, 256. 

Rectophore, 253. 

Rectal Feeding in Appendicitis, 476. 

in Fever, 511. 

in Gastric Ulcer, 367-369. 

in Ileus, 436. 

in Motor Insufficiency, 387. 

in Tuberculosis, 328. 

Irrigation in Gastric Ulcer, 368. 



Purgation, 456. 
Recurrent Glandular Fever, 90. 
Red Light in Smallpox, 584, 585. 
Reduced Iron in Anemia, 80. 

in Chlorosis, 84. 
Reduction Cure, Art of, 154. 

Science of, 151-154. 

in Chronic Rheumatism, 172. 

see Obesity. 
Reflexes from Appendicitis, 480. 
Regurgitation of Food, 410. 
Resorcin in Intestinal Catarrh, 416. 

in Thrush, 262. 
Resorts in Cholelithiasis, 499. 
Rest Cure in Floating Kidney, 235. 

in Palpitation, 67. 

see Weir-Mitchell Treatment. 

in Acute Nephritis, 200. 

in Acute Peritonitis, 469. 

in Aneurism, 57. 

in Appendicitis, 475. 

in Capillary Bronchitis, 293. 

in Cardiac Dropsy, 42. 

in Chlorosis, 81. 

in Cystitis, 243. 

in Diphtheria, 543. 

in Endocarditis, 49. 

in Epididymitis, 253. 

in Failing Compensation, 26. 

in Gastric Ulcer, 368. 

in Gout, 186. 

in Grave's Disease, 105. 

in Heart Disease, 22. 

in Hemoptysis, 308. 

in Hepatic Insufficiency, 495. 

in Intestinal Catarrh, 423. 

in Intestinal Ulcer, 438. 

in Motor Insufficiency, 388. 

in Nervous Diarrhea, 460. 

in Nervous Dyspepsia, 413. 

in Pernicious Anemia, J2. 

in Pulmonary Infarct, 304. 

in Rheumatic Fever, 553. 

in Scurvy, 95. 

in Simple Anemia, 78. 

in Tetanus, 556. 

in Tuberculous Peritonitis, 481. 

in Tuberculosis, 313, 318. 
Rhubarb in Cardiac Dropsy, 44. 

in Constipation, 453. 

in Hepatic Congestion, 40. 
Restriction of Liquids, see Drink Restriction. 

20. 
Retrocedent Gout, 185, 186. 
Rhatany in Intestinal Catarrh, 420. 
Rheumatic Fever, 550-554. 
Rheumatic Gout, 161. 

Pleurisy, 331. 
Rheumatism, 161-172. 

Acute Articular, 161, 550-554. 

Chronic, 162. 

Denfiition, 161. 

Gonorrhceal, 161. 

Infectious, 161. 

Muscular, 162, 163-165. 



622 



Rheumatoid Arthritis, 162, 166-172. 

Synonyms, 162, 163. 
Rhinitis, Acute, 265-269. 
Rice Cure in Diabetes, 129. 
Rickets, see Rachitis. 
Rigid Diabetes Diet, 121, 122. 
Renal Asthma, 280. 
Renal Calculus, see Nephrolithiasis. 

Colic, 232. 

Hemorrhage, 232. 
Roborat Bread, 126. 
Rochelle Salt, 44. 
Room Disinfection, 575. 
Round Worm, 466. 
Rubidium Iodide in Syphilis, 601. 
Rumination, 410. 



Saccharine in Diabetes, 138. 
Salicin in Rheumatic Fever, 551. 
Salicylate poisoning, 551. 
Salicylates in Cholelithiasis, 500, 503. 

in Chronic Rheumatism, 169. 

in Diabetes, 134. 

in Endocarditis, 50. 

in Epididymitis, 254. 

in Hepatic Cirrhosis, 496. 

in Icterus, 487. 

in Muscular Rheumatism, 164. 

in Pericarditis, 52. 

in Pleurisy, 332. 

in Rheumatic Fever, 550-552 . 

in Tonsillitis, 263. 

in Uremia, 238. 
Salicylic Acid in Cystitis, 247. 

Acid in Chronic Gastritis, 356. 

Acid in Fevers, 509. 

Acid in Hay Fever, 270. 

Acid in Intestinal Catarrh, 416. 

Acid in Night Sweats, 327. 

Ointment in Rheumatic Fever, 553. 
Saligenin in Rheumatic Fever, 551. 
Saline Cathartics in Cardiac Dropsy, 44. 

Cathartics in Constipation, 453, 455. 

Waters, 40. 

Waters in Achylia Gastrica, 401. 

Waters in Acute Nephritis, 204. 

Water? in Bronchitis, 284. 

Waters in Chronic Gastritis, 358. 

Waters in Hyposecretion, 401. 

Waters in Icterus, 485, 486. 

Waters in Uremia, 240. 
Saliphen in Rheumatic Fever, 551. 
Saiipyrin in Rheumatic Fever, 552. 
Salisbury Diet, 177. 
Salivation from Calomel, 43. 
Salol in Chronic Rheumatism, 169. 

in Cystitis, 243. 

in Icterus, 488. 

in Intestinal Catarrh, 416. 

in Muscular Rheumatism, 164. 

in Pleurisy, 332. 

in Pyelitis, 223. 

in Rheumatic Fever, 551. 

in Tonsillitis, 263. 



Salt Baths in Bright's Disease, 217. 

Baths, Technique of, 25. 

Enemas in Constipation, 450. 

Enemas in Ileus, 429. 

in Chronic Gastritis, 356. 

Restriction in Heart Disease, 22. 

Restriction in Nephritis, 215. 
Salts in Pleurisy, 336. 
Sand Baths in Chronic Rheumatism, 171. 
Santal Oil in Bronchitis, 282, 284. 

in Cystitis, 244. 
Santonin for Round Worm, 466. 

for Thread Worm, 467. 
Sapo Kalinus in Pseudo-leukemia, 92. 

in Tuberculous Peritonitis, 482. 
Sarcomatosis of Lymph Glands, 90. 
Sassafras as a Carminative, 463. 
Scarification in Dropsy, 46. 

in Epididymitis, 254. 

in Laryngeal Edema, 240. 

Technique of, 39. 
Scarlatina, 567, 571. 
Scarlet Fever, see Scarlatina. 
Schoenlein's Disease, 98. 
Schott Treatment, 23. 
Scopolamine in Pulmonary Edema, 30 r. 
Scottish Douche in Chronic Rheumatism, 
171. 

in Constipation, 449. 
Scrofula, 90. 
Scurvy, 95-96. 

Secondary Anemia, see Simple Anemia. 
Seidlitz Powder in Constipation, 455. 
Self-massage in Constipation, 448. 
Senega in Bronchitis, 283. 
Senna in Cardiac Dropsy, 44. 

in Constipation, 453. 

in Pleurisy, 336. 
Serum of Thyroidectomized Goats, 105. 
Sick Room ' Hygiene, 516, 520. 
Sidonal in Gout, 188. 

in Nephrolithiasis, 231. 
Silver Nitrate in Cystitis, 246. 

in Gastric Ulcer, 372. 

in Hyperchlorhydria, 397. 

in Intestinal Catarrh, 421. 

in Intestinal Ulcer, 439. 

in Scurvy, 96. 

in Stomatitis, 261, 263. 

in Urethritis, 257. 
Simple Anemia, 76-80. 

Goitre, 109. 
Sitz-baths in Constipation, 448-449. 

in Cystitis, 243. 

in Epistaxis, 276. 
Skin Lesions in Diabetes, 141. 

in Obesity, 149. 
Smallpox, 573-586. 
Smelling Salts in Hay Fever, 270. 

in Palpitation, 68. 
Smoking in Constipation, 447. 

in Diabetes, 132. 

in Nervous Dyspepsia, 413. 
Soap Enema in Constipation, 450. 
Sodium Acetate in Bronchitis, 280. 



$2$ 



Acetate in Pleurisy, 336. 

Arseniate in Asthma, 288. 

Arseniate in Tuberculosis, 324. 
Sodium Benzoate in Bronchitis, 282. 284. 

Benzoate in Cholelithiasis, 504. 

Benzoate in Nephrolithiasis, 231. 

Benzoate in Pyelitis, 223. 

Biborate as Mouth Wash, 260. 

Biborate in Hyperchlorhydria, 398. 

Bicarbonate in Achylia Gastrica, 401. 

Bicarbonate in Bright's Disease, 212. 

Bicarbonate in Bronchitis, 280. 

Bicarbonate in Chronic Rheumatism, 169. 

Bicarbonate in Coma, 145. 

Bicarbonate in Gastric Ulcer, 372. 

Bicarbonate in Hyperchlorhydria, 397. 

Bicarbonate in Hyposecretion, 401. 

Bicarbonate in Nephrolithiasis Urica, 228. 

Bicarbonate in Tonsillitis, 263, 264. 

Bromide in Grave's Disease, 107. 

Bromide in Heart Disease, 19. 

Bromide in Palpitation, 68, 69. 

Bromide in Tetanus, 557. 

Bromide in Valve Lesions, 35. 

Cacodylate in Asthma, 288. 

Cacodylate in Leukemia, 88. 

Carcodylate in Pernicious Anemia, 74. 

Cacodylate in Pseudo-leukemia, 91. 

Carcodylate in Pulmonary Edema, 302. 

Cacodylate in Tuberculosis, 324. 

Chloride, see Salt. 

Cinnamate, 324. 

Citrate, 280. 

Glycocholate in Bright's Disease, 207. 

Glycocholate in Cholelithiasis, 500. 

Iodide in Arterio-sclerosis, 55. 

Iodide in Syphilis, 601. 

Nitrate in Hemoptysis, 309. 

Nitrate in Angina Pectoris, 65. 

Salicylate as Mouth Wash, 261. 

Salicylate in Chronic Rheumatism, 169. 

Salicylate in Diabetes, 134. 

Salicylate in Gout, 188. 

Salicylate in Myocarditis, 48. 

Salicylate in Pleurisy, 332. 

Salicylate in Rheumatic Fever, 550. 

Salicylate in Tonsillitis, 263. 

Sulphate as Laxative, 44. 

Sulphate in Dysentery, 560. 

Sulphate in Grave's Disease, 107. 

Sulphate in Hemophilia, 98. 

Sulphocarbolate in Pyelitis, 224. 
Somnolence in Heart Disease, 34. 
Southey Trocars in Dropsy, 45. 
Spasm of the Cardia, 407. 

of the Pylorus, 408. 
Spastic Constipation, 446-447. 
Specific Treatment of Infectious Diseases, 507 
Specifics in Typhoid Fever, 531. 
Specific Sera in Scarlatina, 568. 
Spinal Sponging in Neurasthenia, 405. 
Spigelia for Round Worms, 466. 
Splenectomy in Leukemia, 89. 

Pseudo-leukemia, 93. 
Splenic Anemia, 90. 



Extract in Leukemia, 88. 

Leukemia, 87. 

Tumor in Malaria, 549. 
Splenomegaly, 94. 
Sponging in Icterus, 488. 

in Typhoid Fever, 536. 

Spinal, 405. 
Sporadic Cretinism, 101. 
Sprays in Diphtheria, 542. 

in Hay Fever, 270. 

in Tonsillitis, 264. 
Squills in Pleurisy, 336. 

in Pulmonary Hyperemia, 38. 
Starvation in Acute Nephritis, 199. 

in Acute Peritonitis, 469. 

in Appendicitis, 475. 

in Diabetes, 129. 

in Nervous Dyspepesia, 412. 
Steatorrhea in Diabetes, 142. 
Stegomyia Fasciata in Yellow Fever, 591. 
Stenosis of the Bowel, see Ileus. 
Stomach Tube, 344. 

Passive Congestion of, 40, 41. 
Stomachics in Achylia Gastrica, 401. 

in Chronic Gastritis, 362. 

in Gastric Carcinoma, 381. 

in Hyposecretion, 401. 

in Tuberculosis, 330, 331. 
Stomatitis, 259, 263. 

in Diabetes, 140. 
Stramonium in Asthma, 289, 290. 
Strangulation of the Bowel, 425. 
Strapping in Pleurisy, 335. 
Strontium Bromide in Grave's Disease, 107, 
Strophanthus in Atheroma, 30. 

in Heart Disease, 33. 
Strychnine in Bronchitis, 282-285. 

in Heart Disease, 32. 

in Hemoptysis, 310. 

in Smallpox, 583. 
Stupes in Intestinal Catarrh, 417. 
Stupor in Heart Disease, 34. 
Stypticine in Epistaxis, 274. 

in Internal Hemorrhage, 440. 
Sugar Substitutes, 128. 
Sulphocarbolates in Bright's Disease, 207. 
Sulphonal in Diabetes, 134. 

in Insomnia, 35. 
Sulpho-saline Waters in Chronic Gastritis, 358. 

in Intestinal Catarrh, 422. 
Sulphur in Constipation, 455. 
Sulphuric Acid in Hemophilia, 97. 

in Night Sweats, 326. 

in Purpura, 100. 
Sulphur Waters in Bronchitis, 284. 
Sun Baths in Chronic Rheumatism, 171. 
Sunlight in Smallpox, 584. 
Suppositories in Cystitis, 244. 
Suprarenal, see Adrenal. 

in Heart Disease, 32. 
Surgery in Acute Diffuse Peritonitis, 468. 

in Aneurism, 59. 

in Appendicitis, 471-475, 479-481. 

in Bright's Disease, 222. 

in Bronchiectasis, 286. 



624 



in Cardiac Dropsy, 45. 

in Cholelithiasis, 501-502. 

in Cholecystitis, 505. 

in Chronic Peritonitis, 481. 

in Chronic Rheumatism, 172. 

in Epistaxis, 272. 

in Floating Kidney, 235. 

in Gastritis, 378, 379. 

in Gastric Ulcer, 377. 

in Hepatic Cirrhosis, 497. 

in Hepatic Insufficiency, 497. 

in Ileus, 423. 

in Lung Abscess, 305. 

in Motor Insufficiency, 392. 

in Nephrolithiasis, 232. 

in Prostatitis, 253. 

in Perityphilitis, 471-475. 

in Pulmonary Gangrene, 306. 

in Pyelitis, 224. 

in Tonsillitis, 264, 265. 

in Tuberculosis of the Peritoneum, 
483-484- 
Suspensory in Epididymitis, 254. 
Sweating by Steam, Technique of, 42. 

in Acute Nephritis, 203. 

in Cardiac Dropsy, 42. 

in Chlorosis, 86. 

in Chronic Nephritis, 218, 219. 

in Croup, 543. 

in Diabetes Insipidus, 196. 

in Diphtheria, 542. 

in Muscular Rheumatism, 164. 

in Pleurisy, 333. 

in Pulmonary Edema, 300. 

in Rhinitis, 268. 

in Uremia, 237, 241. 
Swedish Massage, 23. 

Movements in Constipation, 450. 
Syphilis, 594-603. 

and Rachitis, 189. 

as Cause of Anemia, 72. 
Syphilitic Diabetes, 147. 

Hepatitis, 488-497. 

Urethritis, 256, 257. 
Syphonage of Stomach, 345. 



Tachycardia, 70. 

Tenia Mediocanellata, see Tape Worm. 

Solium, see Tape Worm. 
Taka-diastase in Chronic Gastritis, 366. 
Talcum in Gastric Ulcer, 374. 
Talma Operation, 497. 
Tamponade in Epistaxis, 273. 
Tannalbin in Intestinal Catarrh, 420. 

in Intestinal Ulcer, 439. 
Tannic Acid in Hemoptysis, 310. 

in Intestinal Catarrh, 420. 

in Intestinal Ulcer, 439. 

in Salivation, 43. 

in Scurvy, 96. 
Tannigen in Hematuria, 232. 

in Intestinal Catarrh, 420. 

in Intestinal Ulcer, 439. 

in Pyelitis, 223. 



in Uremia, 240. 
Tannin in Diarrhea, 459. 

in Dysentery, 560. 
Tannoform in Night Sweats, 327. 
Tape-worm, 464-466. 

in Pernicious Anemia, 71. 
Tapping, see Paracentesis. 
Tartar Emetic in Acute Gastritis, 343. 

in Bronchitis, 282, 284. 

in Heart Disease, 38. 
Tea, Diuretic, 43, 202. 

in Compensated Heart Lesions, 20. 

in Chronic Nephritis, 214. 
Temperature in Appendicitis, 473. 
Terrain Cure, 23. 

in Obesity, 159. 
Terpine Hydrate in Bronchitis, 282. 
Terpinol in Bronchitis, 282. 
Test Meal, Diabetic, 121, 122. 
Tetanus, 554-557- 
3 1, Antitoxin, 554, 555. 

Tetany in Motor Insufficiency, 387 
Tetronal in Tetanus, 557. 
Thermophore, 39. 

in Cholelithiasis, 503. 

in Ileus, 435. 

in Muscular Rheumatism, 165. 
Theobromin as a Dieuretic, 43. 

in Heart Disease, 32. 

in Pleurisy, 336. 
Thicol in Tuberculosis, 523. 
Thiosanamin in Tetanus, 557. 
Thirst in Acute Gastritis, 343. 

in Acute Peritonitis, 469. 

in Appendicitis, 475. 

in Gastric Ulcer, 368. 

in Ileus, 436. 
Thoracentesis in Pleurisy, 336-339. 
Thread Worm, 467. 
Thrush, 261^ 262. 
Thyme as a Carminative, 463. 
Thymol as Mouth Wash, 261. 

for Anchylostoma, 467. 

for Thread Worms, 467. 

for Uncinaria, 467. 

for Chronic Gastritis, 356. 
Thymus in Grave's Disease, 105. 

in Simple Goitre, 109. 
Thyreoglobulin, 104. 
Thyroid Gland, 101-109. 

in Cretinism, 101. 

in Grave's Disease, 105. 

in Myxedema, 102. 

in Obesity, 160. 

in Simple Goitre, 109. 
Thyroidism, 102-103. 
Thyroidin, 104. 
Tobacco as Cause of Arterio-sclerosis, 53. 

in Compensated Heart Lesions, 20. 

Smoke in Asthma, 290. 
Tolu in Bronchitis, 282, 284. 
Tonics in Diabetes, 133. 

in Syphilis, 601. 
Tonsillar Abscess. 263. 
Tonsillitis, 263-265. 



62 5 



Tracheo Bronchitis, 279-283. 
Tracheotomy in Diphtheria, 544. 
Transfusion in Pernicious Anemia, 74. 

Technique of, 74, 75. 
Tricuspid Insufficiency, 17. 

Stenosis, 17. 
Trigeminal Pulse, 70. 
Trional in Insomnia, 36. 

in Tetanus, 557. 
Trophic Disorders in Diabetes, 144. 
Tropical Dysentery, 558. 
Truneczek Serum in Arterio-sclerosis, 56. 
Tuberculin, 321, 322. 

in Leukemia, 89. 
Tuberculosis of Epididymis, 254. 

of Lungs, 312-331. 

of Peritoneum, 481-484. 
Tuberculous Urethritis, 256. 
Tufnell Diet in Aneurism, 57. 
Tumor in Appendicitis, 474. 
Turkish Bath in Bronchitis, 279. 
Turpentine for Inhalations, 306. 

in Bronchitis, 282, 284. 

in Hemoptysis, 311. 

in Pulmonary Gangrene, 306. 

in Purpura, 100. 

in Renal Colic, 232. 

Typhoid Fever, 531-539- 

U 

Ulcer Gastric, 366-377. 

of. the Bowel, 437-440. 
Ulcerative Stomatitis, 261. 
Uneinaria, 467. 
Urate Deposits, 175. 
Urea in Hepatic Cirrhosis, 496. 

in Nephrolithiasis, 231. 
Uremia, 236-242. 

Acute Attack, 241, 242. 
Uremic Asthma, 286. 

Diarrhea, 413, 458. 
Urethran in Uremic Attack, 242. 
Urethritis, Acute, 248-257. 

Coli Bacillus, 255. 

Gonorrheal, 248-254. 

Non-infectious, 248. 

Posterior, 252. 

Staphylococcus, 255. 

Streptococcus, 255. 

Syphilitic, 256, 257. 

Tuberculosa, 256. 
Uric Acid, Destruction of, 177. 

Diathesis, 173-188. 

Effect of Diet on, 175. 

Elimination of, 177. 

Endogenous, 174. 

Exogenous, 174. 

Pathology of, 173-176. 

Retention of, 174. 

Solvents, 230. 

Transformation of, 174. 
Urichemia, I73f. 



Urinemia, 237. 
Urocine in Gout, 188. 
Urotropin in Cystitis, 244, 245. 

in Nephrolithiasis, 231. 

in Pyelitis, 223. 

in Scarlatina, 570. 

in Urethritis, 255. 
Uva Ursi in Acute Nephritis. 203. 

in Cystitis, 244. 



Vaccination in SmaUpox, 577-579. 
Valerian in Aortic Insufficiency, 19. 

in Diabetes, 134. 

in Diabetes Insipidus, 195. 

in Grave's Disease, 107. 

in Palpitation, 69. 

in Uremic Asthma, 241. 
Valerianate of Quinine in Malaria, 545 
Valvular Disease, 17-47. 

Lesions Compensated, 17-26. 

Lesions Decompensated, 26-34. 
Vasodilators in Angina Pectoris, 63. 
Variola, see Smallpox. 
Venesection in Cerebral Hyperemia, 36. 

in Chlorosis, 86. 

in Emphysema, 298. 

in Epistaxis, 274, 275. 

in Pneumonia, 522. 

in Pulmonary Edema, 303. 

in Pulmonary Hyperemia, 38. 

in Pulmonary Infarct, 305. 

in Uremia, ,242. 

Technique of, 37. 
Veratrum in Epistaxis, 274. 

in Pneumonia, 522. 
Veronal in Insomnia, 36. 
Vesical Gout, 185. 
Vesication, 39. 
Vicarious Epistaxis, 272, 276. 

Hemoptysis, 307. 
Vichy in Diabetes, 136. 

in Intestinal Catarrh, 421. 

in Obesity, 158. 
Vinegar Enema in Constipations, 45<l. 

in Night Sweats, 326. 

in Thread Worms, 467. 

in Scurvy, 96. 
Volatile Oils in Bronchitis, 282, 284. 
Volvulus of the Bowel, 425. 
Vomiting in Acute Peritonitis, 470. 

in Gastric Carcinoma, 382. 

in Motor Insufficiency, 391. 

Nervous, 409. 

in Uremia, 239. 

W 

Water Equilibrium in Heart Disease. 22. 
Weir Mitchell Cure, 405, 406. 
Werlhoff's Disease, 98. 



626 



Wet Packs in Typhoid Fever, 536. 

Whooping Cough, see Pertussis. 

Window Tents, 314. 

Wintergreen Oil in Rheumatic Fever, 551. 

Winternitz Compresses, 411. 

Worms, see Intestinal Parasites. 



X-ray in Malaria Spleen, 549. 
X-rays in Leukemia, 94. 

in Pseudo-leukemia, 93. 

in Splenomegaly, 94. 



Xanthopsia after Santonin, 466. 
Xeroform in Intestinal Catarrh, 



Yeast in Diabetes, 137. 

in Furunculosis, 141 

in Scurvy, 96. 
Yellow Fever, 586-593. 



Zinc Salts in Urethritis, 251. 

Sulphocarbolate in Bright's Disease, 207. 



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